[Treatment of proximal femoral fractures : Principles, tips and tricks]. / Therapie proximaler Femurfrakturen : Grundlagen, Tipps und Tricks.

Proximal femoral fractures occur at an annual incidence of approximately 200/100,000 inhabitants and mortality rates range up to 30% especially in geriatric patients where complications are not necessarily associated to surgery. In nearly all cases surgical treatment is required. Procedures to preserve the femoral head have to be performed as early as possible (as specified by the Federal Joint Committee, GBA, within 24 h). For joint-preserving approaches in medial femoral neck fractures a time to surgery within 6 h is considered to be advantageous. Perioperative patient care is of high importance regarding the prevention of pneumonia, renal failure, delirium and further complications. Postoperatively full weight bearing enables for early mobilization and prevention of surgery-related complications. Nonunions, avascular necrosis of the femoral head, cut-out and prosthetic dislocation must be avoided by the selection of the appropriate procedure. Minimally displaced femoral neck fractures are primarily treated by osteosynthesis and conservative management is only considered in isolated cases. For displaced femoral neck fractures, factors such as a young biological age with high activity levels, the absence of arthritis and good bone quality with a successful reduction favor for a femoral head-preserving osteosynthesis. Otherwise, (hybrid) total hip replacement (THR) is the preferred method for unstable and displaced fractures, whereby hemiarthroplasty should only be considered for very old and patients with pre-existing diseases. Fractures in the trochanteric region are treated with a proximal femoral nail and subtrochanteric fractures are managed using a long proximal femoral nail. To avoid secondary complications, the choice of optimal treatment should be based on a good understanding of the injury pattern, biomechanical and technical aspects of each procedure.

Do hip-abduction braces work?-A biomechanical evaluation of a commercially available hip brace.

INTRODUCTION: Dislocations of the hip joint are a common and clinically relevant complication following total hip arthroplasty (THA). Hip-abduction braces are currently used following operative or non-operative treatment of THA dislocations to prevent re-dislocations. However, the clinical and biomechanical effectiveness of such braces is still controversial. MATERIAL AND METHODS: A total of 30 volunteers were measured during standing and during sitting up and down from a chair task wearing a hip brace set at 70°, 90° or no hip flexion limitation. Range of motion of the hip joint was measured in all directions by an inertial sensor system. Further it has been evaluated if the range of motion would be reduced by the additional use of an arthrodesis cushion. RESULTS: The use of a hip brace set up with flexion limitation did reduce hip ROM in all directions significantly compared to unhinged brace (p < 0.001-0.035). Performing the "sit down and stand-up task" the brace set up at 70° flexion limitation did reduce maximum hip flexion significantly (p = 0.008). However, in most cases the measured hip flexion angles were greater than the settings of the hip brace should have allowed. The additional use of a cushion can further limit hip motion while sitting up and down from a chair. CONCLUSION: This study has demonstrated that hip-abduction braces reduce hip range of motion. However, we also found that to achieve a flexion limitation of the hip to 90°, the hip brace should be set at a 70° hip flexion limitation.

Evaluation of Current Symptoms in Postoperative Achilles Tendons: A Multimodal Ultrasound Study.

(1) Background: It is unknown which imaging parameters are associated with clinical persistent symptoms in postoperative Achilles tendons. This study used B-Mode, Power Doppler (PD-US), Ultrasound Tissue Characterization (UTC) and Shear Wave Elastography (SWE) to investigate which imaging parameters are associated with persistent symptoms in postoperative Achilles tendon tissue. (2) Methods: Retrospective, cross-sectional, multimodal imaging study. Based on the VISA-A score, postoperative tendons were assigned to two groups: 1. asymptomatic (VISA-A ≥ 90, n = 18); 2. symptomatic (VISA-A < 90, n = 10). The following imaging parameters were analyzed: UTC (echo type I, II, III, IV), B-Mode (diameter, cross sectional area, calcification, fiber irregularity), PD-US (Öhberg score) and SWE (SWE 3 mm, SWE area) using a t-test and a Mann-Whitney U test. (3) Results: SWE and PD-US showed significantly reduced elasticity and increased neovascularization in symptomatic tendons (SWE 3 mm p = 0.031, SWE area p = 0.046, Öhberg score p < 0.001). The only significant correlation between imaging parameters and the VISA-A score was assessed for SWE 3 mm (r = 0.378; p = 0.047) and the Öhberg score (r = -0.737; p < 0.001). Conclusions: Symptomatic postoperative Achilles tendons showed increased neovascularization and lower SWE values than asymptomatic ones. Future studies should examine the diagnostic accuracy of PD-US and SWE in detecting current symptoms in postoperative Achilles tendons.

Multimodal Ultrasound Versus MRI for the Diagnosis and Monitoring of Achilles Tendinopathy: A Prospective Longitudinal Study.

BACKGROUND: The diagnosis and monitoring of Achilles tendinopathy with imaging are challenging. There is a lack of studies comparing the diagnostic accuracy of magnetic resonance imaging (MRI), brightness mode ultrasound (B-mode), and power Doppler ultrasound with recent technologies such as ultrasound tissue characterization (UTC) and shear wave elastography (SWE). PURPOSE: To assess whether SWE and UTC, which offer quantitative values, show a superior diagnostic accuracy and capacity to detect structural improvement in Achilles tendinopathy compared with MRI, B-mode, or power Doppler. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients with insertional (n = 28) and midportion (n = 38) Achilles tendinopathy were evaluated at baseline and 6-month follow-up using MRI, B-mode, power Doppler, SWE, and UTC. Asymptomatic controls (n = 37) were evaluated at T 0. Diagnostic accuracy was analyzed based on a quantitative receiver operating characteristic (ROC) analysis with quantitative cutoff values (anteroposterior diameter, Öhberg score, UTC echo type, Young modulus) and by semiquantitative Likert scale-based assessment of experienced physicians. RESULTS: For diagnosing insertional Achilles tendinopathy, semiquantitative MRI and power Doppler were most favorable (diagnostic accuracy, 95%), while the cross-sectional area of MRI revealed 89% accuracy in the ROC analyses (area under the curve [AUC], 0.911; P < .001). For diagnosing midportion Achilles tendinopathy, semiquantitative MRI and B-mode were most favorable (diagnostic accuracy, 87%), while UTC echo types 3 and 4 revealed 86% and 87% accuracy, respectively, in the ROC analyses (AUC, 0.911 and 0.941, respectively; P < .001). However, for quantitative and semiquantitative evaluation of diagnostic accuracy in both insertional and midportion Achilles tendinopathy, there was no significant difference in favor of one imaging modality over the others. Compared with baseline, only SWE showed a significant change at the 6-month follow-up (P = .003-.035), but there were only fair to poor monitoring accuracies of 71% (insertion) and 60% (midportion). However, compared with the other modalities, the monitoring accuracy of SWE was significantly higher (P = .002-.039). CONCLUSION: There was no statistically significant difference in favor of one imaging modality over the others, but MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy.

Adverse Effects of Oxidative Stress on Bone and Vasculature in Corticosteroid-Associated Osteonecrosis: Potential Role of Nuclear Factor Erythroid 2-Related Factor 2 in Cytoprotection.

Significance: Osteonecrosis (ON) is characterized by bone tissue death due to disturbance of the nutrient artery. The detailed process leading to the necrotic changes has not been fully elucidated. Clinically, high-dose corticosteroid therapy is one of the main culprits behind osteonecrosis of the femoral head (ONFH). Recent Advances: Numerous studies have proposed that such ischemia concerns various intravascular mechanisms. Of all reported risk factors, the involvement of oxidative stress in the irreversible damage suffered by bone-related and vascular endothelial cells during ischemia simply cannot be overlooked. Several articles also have sought to elucidate oxidative stress in relation to ON using animal models or in vitro cell cultures. Critical Issues: However, as far as we know, antioxidant monotherapy has still not succeeded in preventing ONFH in humans. To provide this desideratum, we herein summarize the current knowledge about the influence of oxidative stress on ON, together with data about the preventive effects of administering antioxidants in corticosteroid-induced ON animal models. Moreover, oxidative stress is counteracted by nuclear factor erythroid 2-related factor 2 (Nrf2)-dependent cytoprotective network through regulating antioxidant expressions. Therefore, we also describe Nrf2 regulation and highlight its role in the pathology of ON. Future Directions: This is a review of all available literature to date aimed at developing a deeper understanding of the pathological mechanism behind ON from the perspective of oxidative stress. It may be hoped that this synthesis will spark the development of a prophylactic strategy to benefit corticosteroid-associated ONFH patients. Antioxid. Redox Signal. 35, 357-376.

Line- and Point-Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Placebo-Controlled RCT Study.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) is a widely considered treatment option for Achilles tendinopathy. Line-focused ESWT is a novel technique treating a larger tendon area than point-focused ESWT. Monitoring capacities of clinical symptoms with ultrasound under ESWT treatment are unknown. HYPOTHESIS: Point- and line-focused ESWT have a superior outcome than placebo ESWT. ESWT leads to morphological tendon changes detectable with ultrasound. STUDY DESIGN: Single-blinded placebo-controlled randomized contolled trial. LEVEL OF EVIDENCE: Level 1. METHODS: The study was conducted in 3 cohorts, namely ESWT point (n = 21), ESWT line (n = 24), and ESWT placebo (n = 21). Victorian Institute of Sports Assessment-Achilles (VISA-A) score was measured before the intervention (T0), after 6 weeks (T1), and after 24 weeks (T2). All cohorts performed daily physiotherapy for 24 weeks and received 4 sessions of point-focused, line-focused, or placebo ESWT in the first 6 weeks. Ultrasound was performed with B-mode, power Doppler, shear wave elastography (SWE) at T0 and T2 and with ultrasound tissue characterization (UTC) at T0, T1, and T2. Data were analyzed with a mixed analysis of variance and t test. RESULTS: There was a significant VISA-A improvement over time for all groups (P < 0.001). ESWT point had the strongest VISA-A score improvement +23 (ESWT line: +18; ESWT placebo: +15), but there was no significant interaction between time and any of the groups: F(4, 116) = 1.393; P = 0.24. UTC, power Doppler, and B-mode could not show significant alterations over time. SWE revealed a significant increase of elastic properties for ESWT point in the insertion (t = -3.113, P = 0.03) and midportion (t = -2.627, P = 0.02) over time. CONCLUSION: There is a significant VISA-A score improvement for all study groups without a statistically significant benefit for ESWT point or ESWT line compared with ESWT placebo. Tendon adaptation could only be detected with SWE for ESWT point. CLINICAL RELEVANCE: The present study could not detect any statistically relevant effect of ESWT compared to placebo. SWE is able to demonstrate tendon adaptation.

Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study.

INTRODUCTION: Despite the presence of various different surgical procedures, the preferable technique for repair of acute Achilles tendon ruptures is unknown and, therefore, object of discussions. The purpose of this meta-analysis was to compare clinical outcomes and complication-rates between the minimally invasive and the standard open repair of acute Achilles tendon ruptures. MATERIALS AND METHODS: This meta-analysis was performed according to the PRISMA guidelines. In September 2019 the main databases were accessed. All clinical trials of evidence level I to III comparing minimally invasive vs. open surgery of Achilles tendon rupture were included in the present study. Only articles reporting quantitative data under the outcomes of interest were included. Missing data under the outcomes of interest warranted the exclusion from the present work. For the statistical analysis we referred to the Review Manager Software Version 5.3. (The Nordic Cochrane Centre, Copenhagen). Continuous data were analysed through the inverse variance method. For the effect estimate the mean difference was used. Dichotomous data were analysed through the Mante-Haenszel method via odd ratio effect measure. The confidence interval was set at 95% in all the comparisons. Values of P < 0.05 were considered statistically significant. RESULTS: A total of 25 articles were included for meta-analysis. The funnel plot revealed poor data dispersion, attesting to this study a low risk of publication bias. The quality of the methodological assessment was moderate. Data from 2223 (1055 open, 1168 minimally invasive) surgical procedures were extracted. The mean follow-up was of 24.29 ± 22.4 months. The open group reported a lower value of post-operative palpable knot at last follow-up and a lower rate of sural nerve palsy. In the minimally-invasive group a shorter surgery duration and a lower rate of post-operative wound necrosis and reduced risk of wound scarring and adhesions has been evidenced. The minimally-invasive cohort detected the lowest values of superficial and deep infections. In both groups no significant difference was shown in re-rupture rate. CONCLUSIONS: Compared to the minimally-invasive Achilles tendon reconstruction, the open procedure evidenced a lower rate of sural nerve palsy and postoperative palpable knot, whereas in the minimally-invasive reconstruction group quicker surgery duration, a lower rate of post-operative wound necrosis, superficial and deep infections and less scar tissue adhesions could be observed. No relevant discrepancies were detected among the two techniques in terms of post-operative re-rupture.

Partial Achilles Tendon Rupture-A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options.

Partial ruptures in the Achilles tendon are rather uncommon and are often misinterpreted as aggravated Achilles tendinopathy, and not always considered as a differential diagnosis. The aim of this literature review was to characterize typical symptoms, to provide an overview of available diagnosis and treatment options, and to give reference points for future research. There were few studies and sparse knowledge of scientific value, making it difficult to give evidence-based recommendations. Based on the few studies and the authors' clinical experience, a diagnosis should be based on a patient's history with a typical sharp onset of pain and inability to fully load the tendon. Previous intratendinous cortisone injections might be present. Clinical findings are a localized tender region in the tendon and often weakness during heel raises. Ultrasound and Doppler examinations show a region with an irregular and bulging superficial tendon line, often together with localized high blood flow. Magnetic resonance Imaging (MRI) shows a hyperintense signal in the tendon on T1 and T2-weighted sequences. First-line therapy should be a conservative approach using a 2 cm heel lift for the first 6 weeks and avoiding tendon stretching (for 12 weeks). This is followed by a reduced heel lift of 1 cm and progressive tendon loading at weeks 7-12. After 12 weeks, the heel lift can be removed if pain-free, and the patient can gradually start eccentric exercises lowering the heel below floor level and gradually returning to previous sport level. If conservative management has a poor effect, surgical exploration and the excision of the partial rupture and suturing is required. Augmentation procedures or anchor applications might be useful for partial ruptures in the Achilles insertion, but this depends on the size and exact location. After surgery, the 12 to 14-week rehabilitation program used in conservative management can be recommended before the patient's return to full tendon loading activities.

Dynamic spinal posture and pelvic position analysis using a rasterstereographic device.

BACKGROUND: Until recently, rasterstereographic analysis of the spine was limited to static measurements. However, understanding and evaluating the motion of the spine under dynamic conditions is an important factor in the diagnosis and treatment of spinal pathologies. The aim of this study was to study the spinal posture and pelvic position under dynamic conditions and compare it to static measurements using a dynamic rasterstereographic system. METHODS: A total of 121 healthy volunteers (56 females; 65 males) were included in this observational study. The parameters trunk inclination, trunk imbalance, pelvic obliquity, kyphotic angle, lordotic angle, surface rotation, and lateral deviation were studied and compared under static and dynamic (1, 2, 4, 5 km/h) conditions using the system "Formetric 4D Motion®" (DIERS International GmbH, Germany). RESULTS: Female volunteers had a higher lordotic angle than males under static conditions (p < 0.001). Trunk inclination (5.31° vs. 6.74°), vertebral kyphotic angle (42.53° vs. 39, 59°), and surface rotation (3.35° vs. 3.81°) increase under dynamic conditions (p < 0.001). Trunk inclination and lordotic angle both show significant changes during walking compared to static conditions (p < 0.001). CONCLUSION: The spinal posture differs between females and males during standing and during walking. Rasterstereography is a valuable tool for the dynamic evaluation of spinal posture and pelvic position, which can also be used to quantify motion in the spine and therefore it has the potential to improve the understanding and treatment of spinal pathologies. TRIAL REGISTRATION: Retrospectively registered.

Shear wave elastography for treatment monitoring of plantar fasciitis.

BACKGROUND: Plantar fasciitis is a common cause of heel pain. Monitoring therapy effects is challenging with conventional B-mode ultrasound. Shear wave elastography (SWE) provides important diagnostic information beyond B-mode, with typically lower tissue stiffness in symptomatic plantar fascia. Up to now little is known about SWE features for therapy monitoring in plantar fasciitis. We evaluated the clinical effects of a 3-month physical therapy based treatment and its influence on B-mode and SWE ultrasound findings in patients suffering from plantar fasciitis, correlating ultrasound findings to score-based symptom development. METHODS: Prospective, IRB-approved clinical study in plantar fasciitis patients undergoing a 3-month physical therapy based treatment. Measurement time points were before (T0), after 1 (T1) and 3 (T2) months of treatment, consisting of clinical orthopedic (FFI, AOFAS-Score) and multimodal radiologic sonographic examinations (B-mode/SWE) using a high-resolution linear 18-MHz probe. RESULTS: A total of 33 patients with 43 symptomatic plantar fascia were included. We found a significant (P<0.001) clinical score improvement (AOFAS +14, FFI-Pain -21, FFI-Function -18) between T0 and T2. Mean initial thickness (T0) of symptomatic plantar fascia was 4.2 (±1.2) mm, compared to 3.2 (±0.7) mm at the asymptomatic contralateral side (P<0.001). No significant thickness changes were seen at T1 (4.2±1.1 mm) and T2 (4.5±1.3 mm), even though clinical scores improved significantly. Mean initial stiffness (T0) of symptomatic plantar fascia was 59.57 (±43.3) kPa, compared to 83.23 (±47.3) kPa at the asymptomatic contralateral side (P<0.001). In contrast to B-mode ultrasound, SWE values increased significantly between T0 (59.6±43.3 kPa), T1 (82.6±47.3 kPa) and T2 (102.5±47.2 kPa) (P<0.001-0.009), with positive correlations for AOFAS/FFI-Pain/Function scores (r=0.285-0.473, P<0.001-0.002). CONCLUSIONS: A physical therapy based treatment relieves plantar fasciitis symptoms during a 3-month period. In line with symptom reduction, stiffness (Young's-moduli) of plantar fascia increased significantly, while B-mode ultrasound revealed no measurable changes during the healing process. Shear wave elastography was able to quantify plantar fascia pathologies and their recovery under therapy.

Intra individual comparison of unilateral Achilles tendinopathy using B-mode, power Doppler, ultrasound tissue characterization and shear wave elastography.

BACKGROUND: The asymptomatic side of unilateral Achilles tendinopathy (AT) is used as a reference in ultrasound. However, this procedure has not been evaluated in a comparative analysis using B-mode (B-US), power Doppler (PD-US), ultrasound tissue characterization (UTC) and shear wave elastography (SWE). METHODS: Retrospective cross-sectional study. Tendons were assigned to 3 groups: 1) asymptomatic side of unilateral AT N.=55; 2) symptomatic side of unilateral AT N.=55; and 3) young reference group N.=29. The following parameters were analyzed separately for the insertion and midportion: UTC (echo type I, II, III, IV), B-US (diameter, cross sectional area), PD-US (Öhberg Score) and SWE (SWE 3 mm, SWE area) using a Wilcoxon Test (group 1 vs. 2) and a Kruskal-Wallis Test (group 1 vs. 2 vs. 3). RESULTS: The Wilcoxon Test making an isolated comparison between group 1 vs. 2 revealed a significant difference for all parameters of B-US, PD-US, UTC and SWE (P<0.001, P=0.042), except for the insertion in UTC. However, in the overall analysis including the reference group, the Kruskal-Wallis Test could only detect a significant difference between group 1 vs. 2 for PD-US (P<0.001). Thus, group 1 and 2 had significantly more pathological parameters in B-US (P<0.001, P=0.027), SWE (P<0.001, P=0.008) and UTC (type I, III, IV P<0.001) in both, insertion and midportion, compared to the reference group. CONCLUSIONS: The asymptomatic side of unilateral AT seems to show subclinical tendons alterations in B-US, SWE and UTC in comparison to a young and healthy control group. The asymptomatic side of unilateral AT especially with detectable neovascularization might be at risk for future symptoms. Further studies must examine whether the asymptomatic side can still serve as a reference for intra individual comparison in clinical evaluation.

Arthroscopic surgery versus physiotherapy for femoroacetabular impingement: a meta-analysis study.

INTRODUCTION: Femoroacetabular impingement (FAI) is thought to play an important role in the development of hip osteoarthritis. However, there is no consensus about the optimal treatment options, since non-operative therapy such as physiotherapy and surgical treatment such as arthroscopic hip surgery can both improve symptoms. Therefore, the aim of the present meta-analysis was to compare the outcomes between two different treatment regimes; physiotherapy versus arthroscopic treatment for FAI. METHODS: The present meta-analysis was carried out according to the PRISMA guidelines. In November 2019, the main online databases were accessed. All the randomized clinical trials (RCTs) comparing surgical arthroscopic treatment versus physiotherapy for FAI were considered for inclusion. Only articles reporting quantitative data under the outcomes of interest were included. For the all analysis, we used Review Manager Software. Data from 644 patients were analysed. RESULTS: Data from 644 patients were evaluated with a mean follow-up of 14.67 ± 8.3 months. The unpaired t test detected an optimal baseline comparability in terms of side, gender, years, duration of symptoms and BMI (p = 0.08-0.9). The VAS subscale of the score EQ-5D and the mean iHOT33 reported favourable values in the arthroscopic group (p = 0.03 and p < 0.0001, respectively). Similar findings were evidenced in the iHOT33 subgroup 6-months (p = 0.70) and 12-months (p = 0.0002). The HOS score, the ADL (p < 0.0001) and the sport (p = 0.0003) subscales reported both greater values in the arthroscopic group. No statistical significance was found concerning the risk to incur in further total hip arthroplasty (p = 0.72). CONCLUSION: Based on only three high-quality RCTs, arthroscopic hip surgery is an effective therapeutic treatment for FAI revealing superior results than a non-surgical approach with physiotherapy.

Anterior knee pain after total knee arthroplasty: A multifactorial analysis.

PURPOSE: Dissatisfaction and an impaired quality of life after total knee arthroplasty (TKA) is often associated with postsurgical anterior knee pain (AKP). The underlying pathological mechanisms are not yet fully understood. Therefore, a multifactorial approach encompassing clinical and radiological parameters seemed reasonable and promising to investigate postsurgical AKP. METHODS: In this cross-sectional study, 25 patients without and 25 patients with postsurgical AKP after unilateral TKA were randomly recruited from a larger cohort of patients. Multiple clinical and radiological parameters-including real-time shear wave elastography (SWE) to measure the patellar and quadriceps tendon elasticity-were acquired and subsequently associated with AKP. For statistical analysis, SPSS (IBM, version 25) was used. RESULTS: In total 50 participants (58.0% men, mean age 63.42 years, mean body mass index 29.75 kg/m2), having different prosthetic designs implanted, were included. Independently of key covariates, the strength of the quadriceps muscle (p = 0.021), a thinner inlay (p = 0.041), and a lower position of the patella (p = 0.041) were associated with AKP. Although no correlation with AKP was found (p = 0.346, resp. p = 0.154), we observed significantly decreased Young's modulus of the patellar and quadriceps tendons for the involved knee compared to the uninvolved knee (p < 0.001). CONCLUSION: In conclusion, quadriceps muscle strength, inlay thickness, and the patella position might be of particular relevance in avoiding postsurgical AKP. Future studies with larger sample sizes are needed to clarify the impact of quadriceps muscle strength and the postoperative patella position as well as the role of SWE as a personalized modifiable prediction marker.

Short stems for total hip replacement among middle-aged patients.

INTRODUCTION: The purpose of the present study was to investigate the role of short stem implants for primary total hip arthroplasty in middle-aged patients. For this purpose, a meta-analysis of the current literature was conducted. The focus was on clinical outcomes,radiological parameters, and further complications of both components. MATERIAL AND METHODS: The study was performed according to the PRISMA guidelines. All randomized and non-randomized clinical trials comparing short stem versus standard stem prostheses for THA were considered for inclusion. Only studies reporting data concerning uncemented stems for primary total hip arthroplasty were included. Only studies reporting data concerning patients with a mean age of 45 to 69 were included. RESULTS: A total of 2197 procedures in 2116 patients were analysed. The mean follow-up was 30.2 months. The short stem group showed a statistically significant higher WOMAC score and a reduced total estimated blood loss compared with the standard stem group. The short stem group showed a reduced rate of femoral fractures, dislocations, and revision, but without statistical significance. CONCLUSIONS: According to the main findings of this meta-analysis and current evidence, we encourage the use of the uncemented short stems during primary total hip arthroplasty in middle-aged patients.

Surgical versus conservative treatment for first patellofemoral dislocations: a meta-analysis of clinical trials.

INTRODUCTION: The first approach for acute patellar dislocation is still a debated topic. The purpose of the present study was to perform a meta-analysis evaluating the outcomes of the surgical approach compared to the conservative treatments for primary acute patellar dislocation. We hypothesize that a prompt surgical treatment may lead to better outcomes in terms of re-dislocations and quality of life. METHODS: This meta-analysis was performed according to the PRISMA guidelines. All the prospective clinical trials comparing surgical and conservative treatment for first acute patellofemoral dislocation were included in this study. For the methodological quality assessment, the PEDro appraisal score was adopted. For the risk of publication bias, the funnel plot was performed. The statistical analysis was performed using the Review Manager Software 5.3 (The Nordic Cochrane Collaboration, Copenhagen). RESULTS: The funnel plot detected a low risk of publication bias. According to the PEDro score, the methodological quality assessment was good. Data from 654 patients were collected, undergoing a mean of 53.8 ± 48.4 month follow-up. A total of 311 patients (17.66 ± 4.1 years old) were analyzed in the surgery group and 291 patients (19.25 ± 4.5 years old) in the conservative ones. The mean Kujala score resulted in greater favor of the surgery group (MD: 9.99%; P = 0.006). The analysis of the comparison of re-dislocations resulted in favor of the surgery group (OR: 0.41; P < 0.0001). The analysis of the comparison of persistent joint instability resulted in favor of the surgery group (OR: 0.41; P < 0.0001). CONCLUSIONS: Data from the present study encourage a prompt surgical approach for the first patellofemoral dislocation.

Eccentric and Isometric Exercises in Achilles Tendinopathy Evaluated by the VISA-A Score and Shear Wave Elastography.

BACKGROUND: Apart from eccentric exercises (EE), isometric exercises (ISO) might be a treatment option for Achilles tendinopathy. Shear wave elastography (SWE) provides information for diagnosis and for monitoring tissue elasticity, which is altered in symptomatic tendons. HYPOTHESIS: Isometric exercises will have a beneficial effect on patients' outcome scores. Based on SWE, insertional and midportion tendon parts will differ in their elastic properties according to current symptoms. STUDY DESIGN: Randomized clinical trial. LEVEL OF EVIDENCE: Level 2. METHODS: Group 1 (EE; n = 20; 12 males, 8 females; mean age, 52 ± 8.98 years) and group 2 (EE + ISO; n = 22; 15 males, 7 females; mean age, 47 ± 15.11 years) performed exercises for 3 months. Measurement points were before exercises were initiated as well as after 1 and 3 months using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score, American Orthopaedic Foot & Ankle Society score, and SWE (insertion and midportion). RESULTS: Both groups improved significantly, but there were no significant interindividual differences (VISA-A; P = 0.362) between group 1 (n = 15; +15 VISA-A) and group 2 (n = 15; +15 VISA-A). The symptomatic insertion (symptomatic, 136.89 kPa; asymptomatic, 174.68 kPa; P = 0.045) and the symptomatic midportion of the Achilles tendon (symptomatic, 184.40 kPa; asymptomatic, 215.41 kPa; P = 0.039) had significantly lower Young modulus compared with the asymptomatic tendons. The midportion location had significantly higher Young modulus than the insertional part of the tendon (P = 0.005). CONCLUSION: Isometric exercises do not have additional benefit when combined with eccentric exercises, as assessed over a 3-month intervention period. SWE is able to distinguish between insertional and midportion tendon parts in a symptomatic and asymptomatic state. CLINICAL RELEVANCE: The present study shows no additional effect of ISO when added to baseline EE in treating Achilles tendinopathy. Different elastic properties of the insertional and midportion tendon have to be taken into consideration when rating a tendon as pathologic.

Evaluation of Postoperative Changes in Patellar and Quadriceps Tendons after Total Knee Arthroplasty-A Comprehensive Analysis by Shear Wave Elastography, Power Doppler and B-mode Ultrasound.

RATIONALE AND OBJECTIVES: Up to now, the diagnosis of tendinopathies is based on conventional B-mode-ultrasound (B-US), Power Doppler-ultrasound (PD-US), and magnetic resonance imaging. In the past decade, Shear Wave Elastography (SWE) has been introduced in tendon imaging, for example in athletes or patients suffering from tendinopathy. SWE allows real-time quantification of tissue stiffness, and, by this, the assessment of the mechanical properties of a tendon and its changes during acute disease and tendon healing. So far there are no ultrasound-based studies that have evaluated postoperative tendon changes, anatomical and mechanical properties and tendon healing of the patellar, and quadriceps tendon following Total Knee Arthroplasty (TKA). The purpose of this prospective study was two-fold: first to analyze morphologic, vascular, and mechanical properties of patellar and quadriceps tendons in patients following TKA; and, second to evaluate possible changes thereof and their visibility in the course of time. MATERIALS AND METHODS: Observational cross-sectional, IRB-approved study in 63 postoperative patients with a total of 76 total knee arthroplasties (50 unilateral, 13 bilateral) and 50 nonoperated knees for comparison, resulting in 152 postoperative patellar- and quadriceps and 100 nonoperated patellar- and quadriceps-tendons for comparative analysis. For further examination, we divided the 63 patients into two groups according to the duration since surgery (group A < 24 months; group B > 24 months). All patients completed a standardized questionnaire, furthermore the Knee Society score and the Knee Society function score. The amount of experienced pain was assessed using the ordinal numeric rating scale and the presence of anterior knee pain was examined. Subsequently every participant underwent a standardized multimodal ultrasound protocol consisting of B-US, PD-US, and SWE of the left and right patellar and quadriceps tendons. RESULTS: Using the different US-modalities, operated patellar, and quadriceps tendons (n = 152) were significantly more frequent classified as pathological (B-US) (p < 0.001), the mean Ohberg score was significantly higher (PD-US) (p < 0.001), and the tendons were significantly softer (SWE) than their nonoperated counterparts (n = 100). Mean SWE-value of postoperative patellar tendons was 45.66 ± 14.84 kPa versus 60.08 ± 19.13 kPa in nonoperated knees (p < 0.001). Mean SWE-value of postoperative quadriceps tendons was 35.73 ± 15.66 kPa versus 52.69 ± 16.20 kPa in nonoperated knees (p < 0.001). Comparing the two postoperative groups (group A and B), we recognized a significant decrease of pathologically classified patellar and quadriceps tendons (B-US and PD-US) in group B. The early postoperatively reduced SWE values slightly increased during the course of time. CONCLUSION: After TKA, patellar, and quadriceps tendons show significant measurable alterations in B-US, PD-US, and SWE. Especially a significant decrease of tendon stiffness in operated knees, as assessed by SWE, might be a surrogate marker for changed mechanical properties. These alterations improve, the longer ago the surgery was. The quantitative information obtained by SWE could be of particular interest in follow-up and therapy monitoring after TKA. Knowledge about tendon stiffness and it's varieties in different population groups (e.g. athletes, elderly, postoperative patients) is crucial to sonographically rate a tendon as "healthy" or "diseased."

Shear Wave Elastography (SWE) for the Evaluation of Patients with Plantar Fasciitis.

RATIONALE AND OBJECTIVES: The current imaging standard for diagnosing plantar fasciitis is B-Mode ultrasound (B-US). The aim of this study was to determine the diagnostic potential of Shear Wave Elastography (SWE) and the correlation of clinical scores to elastographic parameters. MATERIALS AND METHODS: Diagnostic case-control study with n = 82 plantar fascia (PF). PF were divided into three subgroups: (1) symptomatic PF (n = 39); (2) control group of unilateral asymptomatic PF (n = 23); (3) bilateral asymptomatic PF (n = 20). Reference standard for positive findings in B-US was a PF thickness greater than 4 mm. For SWE tissue elasticity (Young's modulus kPa; shear wave speed m/s) was measured at Location 1: directly at the calcaneus; Location 2: +1 cm distal of the calcaneus and Location 3: central part of the calcaneus. Sensitivity, specificity, and diagnostic accuracy as well as correlation to American Orthopaedic Foot and Ankle Score (AOFAS) and Food Functional Index (FFI) were determined. RESULTS: Symptomatic PF are thicker (4.2 mm, n = 39) than asymptomatic (3.0 mm, n = 43) (p < 0.001). Thickness of the PF (n = 82) correlated poorly to clinical scores (p = 0.001): FFI-pain (r = 0.349); FFI-function (r = 0.381); AOFAS (r = -0.387). Cut-off point for positive SWE finding was 51.5 kPa (4.14 m/s). Symptomatic PF (31.9 kPa, 3.26 m/s, n = 39) differ significantly from asymptomatic PF (93.3 kPa, 5.58 m/s, n = 43) with significant differences at L1 between all groups (p < 0.001). Correlation between Young's modulus (n = 82) and clinical scores was strong (p < 0.001): FFI-pain (r = -0.595); FFI-function (r = -0.567); AOFAS (r = 0.623,). B-US: sensitivity (61%), specificity (95%); SWE sensitivity (85%), specificity (83%). The combination of SWE and B-US increases the sensitivity (100%) with a diagnostic accuracy of 90%. CONCLUSION: Based on our results, we could show that SWE can improve the diagnostic accuracy in patients with plantar fasciitis compared to B-US. LEVEL OF EVIDENCE: II.

Shear Wave Elastography (SWE) of Asymptomatic Achilles Tendons: A Comparison Between Semiprofessional Athletes and the Nonathletic General Population.

RATIONALE AND OBJECTIVES: It has been shown that Shear Wave Elastography (SWE) is a useful tool to evaluate tendon stiffness, e.g. in diagnosing tendinopathies, as diseased or injured tendons are intra-individually softer than healthy ones. But reference values between different population groups are still missing. The purpose of this prospective clinical study was two-fold: First, to comparatively analyse Achilles tendon stiffness between asymptomatic semiprofessional athletes and an asymptomatic nonathletic control group. Second, to evaluate specificity, with which SWE is able to predict absence of clinical symptoms in asymptomatic individuals, compared to B-mode-Ultrasound (B-US) and Power Doppler-Ultrasound (PD-US). MATERIALS AND METHODS: Prospective clinical study in 68 asymptomatic healthy participants, 33 (48.5%) of them semiprofessional athletes with at least five training units of running per week and 35 (51.5 %) normal nonathletic persons, asymptomatic respectively. A consecutive of 136 Achilles tendons underwent standardized multi-modal ultrasound, consisting of B-US, PD-US, and SWE (Aixplorer, Supersonic). Pathologic structural changes at B-US, increased Doppler signal PD-US and quantitative ROI-based-analysis of tendon elasticity in kilopascal (kPa) were performed in all participants. Tendon stiffness was compared intra-individually between right and left side in each participant. SWE values between athletes and nonathletes were compared by using student's t test (p < 0.05). To evaluate the ability of different sonographic modalities in predicting "absence of clinical symptoms", specificities of B-US, PD-US, and SWE were calculated and compared among each other. RESULTS: Mean SWE-value for Achilles tendon was 183.8 kPa (± 98 kPa) in athletes and 103.6 kPa (± 30.5 kPa) in the nonathletic control group. The difference between athletes and non-athletes was statistically significant (p < 0.001). No significant differences were found intra-individually between right and left side: athlete mean: right: 187.2 kPa (SD ± 45.2 kPa)/left: 180.4 kPa (SD 39.7 kPa); nonathlete mean: right: 105.4 kPa (SD 34.9 kPa)/left: 101.8 kPa (SD 28.9 kPa). Specificity with which asymptomatic tendons were rated as "inconspicuous" was 60.6% for B-US, 93.9% for PD-US and 96.3% for SWE. CONCLUSION: Healthy athletes exhibit significantly higher SWE-values in Achilles tendons than healthy nonathletic participants, which means that they have significantly stiffer tendons, possibly caused by repeated training. SWE is able to measure and display these effects. These interindividual differences should be taken into consideration, especially when rating a tendon as "healthy" or "diseased", because a "softer" tendon does not necessarily mean to be affected.

Shear Wave Elastography (SWE) for Monitoring of Treatment of Tendinopathies: A Double-blinded, Longitudinal Clinical Study.

RATIONALE AND OBJECTIVES: We aimed to investigate the diagnostic accuracy with which shear wave elastography (SWE) can be used to monitor response to treatment of tendinopathies, and to compare it to conventional ultrasound (US)-imaging methods (B-mode US (B-US) and power Doppler US (PD-US)). MATERIALS AND METHODS: A prospective Institutional Review Board-approved longitudinal study on 35 patients with 47 symptomatic tendons (17 Achilles-, 15 patellar-, and 15 humeral-epicondylar) who underwent standardized multimodal US and standardized clinical assessment before and after 6 months of treatment (tailored stretching exercise, sport break, and local Polidocanol) was carried out. All US studies were performed by radiologists blinded to the clinical symptoms on both tendon sides to avoid biased interpretations, by B-US, PD-US, and SWE, conducted in the same order, using a high-resolution linear 15 MHz probe (Aixplorer). Orthopedic surgeons who were in turn blinded to US imaging results used established orthopedic scores (Victorian Institute of Sports Assessment questionnaire for Achilles, Victorian Institute of Sports Assessment questionnaire for patellar tendons, and Disability Arm Shoulder Hand scoring system) to rate presence, degree, and possible resolution of symptoms. We analyzed the diagnostic accuracy with which the different US imaging methods were able to detect symptomatic tendons at baseline as well as treatment effects, with orthopedic scores serving as reference standard. RESULTS: B-US, PD-US, and SWE detected symptomatic tendons with a sensitivity of 66% (31 of 47), 72% (34 of 47), and 87.5% (41 of 47), respectively. Positive predictive value was 0.67 for B-US, 0.87 for PD-US, and 1 for SWE. After treatment, clinical scores improved in 68% (32 of 47) of tendons. Treatment effects were observable by B-US, PD-US, and SWE with a sensitivity of 3.1% (1 of 32), 28.1% (9 of 32), and 81.3% (26 of 32), respectively. B-US was false-positive in 68.8% (20 of 32), PD-US in 46.9% (15 of 32), and SWE in 12.5% (4 of 32) (SWE). Clinical scores and B-US, PD-US, and SWE findings correlated poorly (r = 0.24), moderately (r = 0.59), and strongly (r = 0.80). CONCLUSION: Unlike B-US or PD-US, SWE is able to depict processes associated with tendon healing and may be a useful tool to monitor treatment effects.