Efficacy of quadruple treatment on different types of pre-operative anaemia: secondary analysis of a randomised controlled trial.

In patients with pre-operative anaemia undergoing cardiac surgery, combination treatment with intravenous iron, subcutaneous erythropoietin alpha, vitamin B12 and oral folic acid reduces allogeneic blood product transfusions. It is unclear if certain types of anaemia particularly benefit from this treatment. We performed a post-hoc analysis of anaemic patients from a randomised trial on the 'Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery'. We used linear regression analyses to examine the efficacy of a combination anaemia treatment compared with placebo on the following deficiencies, each representing a part of the combination treatment: ferritin and transferrin saturation; endogenous erythropoietin; holotranscobalamine; and folic acid in erythrocytes. Efficacy was defined as change in reticulocyte count from baseline to the first, third and fifth postoperative days and represented erythropoietic activity in the immediate peri-operative recovery phase. In all 253 anaemic patients, iron deficiency was the most common cause of anaemia. Treatment significantly increased reticulocyte count in all regression analyses on postoperative days 1, 3 and 5 (all p < 0.001). Baseline ferritin and endogenous erythropoietin were negatively associated with change in reticulocyte count on postoperative day 5, with an unstandardised regression coefficient B of -0.08 (95%CI -0.14 to -0.02) and -0.14 (95%CI -0.23 to -0.06), respectively. Quadruple anaemia treatment was effective regardless of the cause of anaemia and its effect manifested early in the peri-operative recovery phase. The more pronounced a deficiency was, the stronger the subsequent boost to erythropoiesis may have been.

Degenerative isolated cartilage defects of the patellofemoral joint are associated with more severe symptoms compared to trauma-related defects: results of the German Cartilage Registry (KnorpelRegister DGOU).

PURPOSE: The purpose of this study was to utilize data from the German Cartilage Registry (KnorpelRegister DGOU) to examine the hypothesis that degenerative cartilage defects of the patellofemoral joint are associated with more severe clinical symptoms compared to trauma-related defects. METHODS: All patients with isolated focal cartilage defects of the patellofemoral joint registered in the German Cartilage Registry until May 2017 were included in the study. Patients with previous surgery of the ipsilateral knee were excluded. Baseline data including etiology (traumatic, degenerative), size, location and ICRS grade of the cartilage defects as well as the duration of symptoms were analyzed. Clinical symptoms were evaluated by means of the numeric analog scale (NAS) for pain and the Knee injury and Osteoarthritis Outcome Score (KOOS). Group comparisons were performed using the Mann-Whitney-U test along with the Chi-squared test and Fisher's exact test. A bivariate correlation analysis and a multivariable linear regression analysis were performed to investigate the association between the defect characteristics and the clinical scores. RESULTS: A total of 423 patients (203 traumatic and 220 degenerative defects) were included. Isolated degenerative cartilage defects were found to have significantly more trochlear locations (28% vs. 18%; p = 0.006), significantly less ICRS grade 4 lesions (50% vs. 73%; p = 0.002) and a significantly smaller defect size [median 300 (IQR 105-400) vs. 300 (200-400) mm2] when compared to those from traumatic etiology. Traumatic defects showed significantly better KOOS-ADL [77 (60-90) vs. 69 (56-82); p = 0.005], KOOS-pain [69 (56-81) vs. 61 (47-75); p = 0.001] and NAS [2 (1-5) vs. 4 (1-6); p = 0.005] scores compared to degenerative defects. The correlation analysis revealed only weak correlations between the quantitative defect characteristics and clinical scores. CONCLUSIONS: Degenerative isolated cartilage defects in the patellofemoral joint are associated with more severe clinical symptoms in comparison to trauma-related defects. Additionally, they show a larger variance regarding their location with more trochlear defects. LEVEL OF EVIDENCE: III.

[Treatment of Osteochondral Lesions in the Ankle: A Guideline from the Group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU)]. / Behandlung osteochondraler Läsionen des Sprunggelenks: Empfehlungen der Arbeitsgemeinschaft Klinische Geweberegeneration der DGOU.

Background: Osteochondral lesions (OCL) of the ankle are a common cause of ankle pain. Although the precise pathophysiology has not been fully elucidated, it can be assumed that a variety of factors are responsible, mainly including traumatic events such as ankle sprains. Advances in arthroscopy and imaging techniques, in particular magnetic resonance imaging (MRI), have improved the possibilities for the diagnosis of OCLs of the ankle. Moreover, these technologies aim at developing new classification systems and modern treatment strategies. Material and Methods: This article is a review of the literature. Recommendations of the group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU) for the treatment of OCLs of the ankle are presented. The review gives a concise overview on the results of clinical studies and discusses advantages and disadvantages of different treatment strategies. Results: Non-operative treatment shows good results for selected indications in children and adolescents, especially in early stages of osteochondritis dissecans (OCD). However, surgical treatment is usually indicated in OCLs in adolescents and adults, depending on the size and location of the lesion. Various arthroscopic and open procedures are frequently employed, including reattachment of the fragment, local debridement of the lesion with fragment removal and curettage of the lesion, bone marrow-stimulation by microfracture or microdrilling (antegrade or retrograde), and autologous matrix-induced chondrogenesis (AMIC®) - with or without reconstruction of a subchondral bone defect or cyst by autologous cancellous bone grafting. Isolated subchondral cysts with an intact cartilage surface can be treated by retrograde drilling and possibly additional retrograde bone grafting. For larger defects or as salvage procedure, osteochondral cylinder transplantation (OATS® or Mosaicplasty®) or matrix-induced autologous chondrocyte transplantation (MACT) are recommended. Transplantation of so-called (osteochondral) mega grafts, such as autologous bone grafts or allografts, are used for very large osteochondral defects that cannot be reconstructed otherwise. Implantation of the so-called "small metal implants" - such as HemiCAP Talus® - is reserved for selected cases after failed primary reconstruction. Corrective osteotomies are indicated in accompanying axial malalignments. Conclusions: There are several different treatment strategies for OCLs, but clinical studies are rare and evidence is limited. Therefore, interventional studies, e.g. randomised controlled trials (RCTs), but also observational studies, e.g. based on data of the Cartilage Registry of the German Society of Orthopaedics and Traumatology (www.knorpelregister-dgou.de), are needed and are recommended by the authors.

[Bone Marrow Lesion - Risk-Factors and Pathophysiological Relevance: Systematic Review]. / Bone Marrow Lesion - Risikofaktoren und pathophysiologische Bedeutung: systematisches Review.

AIM: The objective of this systematic review and meta-analysis is to obtain information about risks and associated factors for knee symptoms and the progression of osteoarthritis in idiopathic bone marrow lesion (BML). MATERIALS AND METHODS: The primary search on 31. 12. 2013 included the databases PubMed, EMBASE, Web of Science and Cochrane by the search strategy [[bone marrow edema] AND [knee]]. This review was continuously updated up to 31. 10. 2015. RESULTS: A total of 30 studies (from 1331 primary findings) were included in the final evaluation. The mean frequency of BML in all studies was 37.2 %. The occurrence of BML was strongly dependent on the MRI technique used (1.0 to 3.0 T). In longitudinal studies, the incidence of BML was 3.2 (95 % CI 1.7-6.3)/1000 person-months. Weakly associated factors included female gender (OR = 1.3 [95 % CI 1.1-1.7], p = 0.009), increasing age (OR = 1.05 [95 % CI 0.9-1.3], p = 0.127), and overweight or obesity (OR = 1.1 [95 % CI 1.1-1.2]; p < 0.01). BMLs are significantly associated with cartilage lesions (OR = 5.5 [95 % CI 1.3-22.5]). Radiological osteoarthritis is also significantly associated with the development of BML (OR = 3.6 [95 % CI 1.2-10.6]) and the progression of osteoarthritis within a 3-year interval (OR = 4.4 [95 % CI 3.1-6.4]). CONCLUSIONS: The occurrence of BML is an important index for severe degenerative pathologies in the knee. It appears that MRT symptoms predict the progression of the disease. The clinical relevance and possible consequences for treatment are unclear.

[Magnetic Resonance Imaging, Arthroscopy and Near-Infrared Spectroscopy (NIRS) for Grading Osteoarthritis in the Knee]. / Methodenvergleich von Kernspintomografie, Arthroskopie und Nah-Infrarot-Spektroskopie (NIRS) bei der Bestimmung des Arthrosegrads des Kniegelenks.

PURPOSE: This study was aimed to evaluate the meaningfulness of the MRI Score WORMS (Whole Organ Magnetic Resonance Imaging), the arthroscopic WOAKS (Whole Organ Arthroscopic Knee Score) and the result of NIRS (near-infrared spectroscopy) measurements. MATERIALS AND METHODS: A total of 49 patients with knee pain (> 3 months) underwent MRI with a standardised protocol. In the results the WORMS was calculated. The WOAKS was calculated from the results of an arthroscopic evaluation. In the same procedure, NIRS measurements were performed in the identical 14 regions of interest. From these measurements, the WOAKS_NIRS was calculated. RESULTS: The highest grade of degeneration in all evaluations was found in the patella. The medial compartment showed moderate lesions compared with the lateral compartment. The relative WORMS was only 3.7 % (95 % CI 2.8-4.6; 0-15.6 %). During arthroscopy, we calculated a mean WOAKS of 15.2 % (95 % CI 13.2-17.2; 5-39 %). The degree of joint degeneration was highest in NIRS measurements. The mean WOAKS_NIRS was 50.9 % (95 % CI 48.1-53.7 %). These differences are significant (p < 0.001). CONCLUSION: The methods to detect early cartilage degenerations in MRI are flawed. Thus in our patients, we detected a full grade of degeneration in only 3.7 % of the patients. Arthroscopy mostly gives higher damage within the knee joint. The initial stages of cartilage lesion are usually undetectable. Spectroscopy has the best sensitivity for the evaluation of early degeneration within the hyaline cartilage. The clinical relevance of our results is still unclear. Further outcome studies are needed.

[The German Cartilage Registry (KnorpelRegister DGOU) for evaluation of surgical treatment for cartilage defects: experience after six months including first demographic data]. / Das KnorpelRegister DGOU zur Erfassung von Behandlungsergebnissen nach Knorpeloperationen: Erfahrungen nach 6 Monaten und erste epidemiologische Daten.

The German Cartilage Registry (KnorpelRegister DGOU) has been introduced in October 2013 and aims on the evaluation of patients who underwent cartilage repair for symptomatic cartilage defects. It represents a nation-wide cohort study which has been introduced by the working group "Tissue Regeneration" of the Germany Society of Orthopaedic Surgery and Traumatology and is technically based upon a web-based remote data entry (RDE) system. The present article describes first experiences with the registry including patient and treatment characteristics. Between October 2013 and April 2014, a total of 230 patients who had undergone surgical cartilage repair for symptomatic full-thickness cartilage defects of the knee has been included in the German Cartilage Registry from 23 cartilage repair centres. Mean age was 37.11 years (SD 13.61) and mean defect size was 3.68 cm(2) (SD 0.23). Since the introduction of the KnorpelRegister DGOU the total number of registered patients has increased steadily up to the most recent figure of 72 patients within one month. Patients were treated mainly according to the recommended therapies. The highest percentage in therapy is represented by the bone marrow stimulation techniques (55.02 %) as well as by the autologous chondrocyte transplantation (34.92 %). Unlike the patient collective in the majority of prospective randomised controlled trials, the patient population within the registry shows a high proportion of patients with accompanying pathologies, with an age of more than 50 years at the time of treatment and with unfavourably assessed accompanying pathologies such as an affection of the opposite cartilage surface or a previously resected meniscus. In summary, the technical platform and forms of documentation of the KnorpelRegister DGOU have proved to be very promising within the first six months. Unlike data from other clinical trials, the previous analysis of the patients' data and therapies reflects successfully the actual medical care situation of patients with cartilage defects of the knee joint. This analysis also provides new information on subgroups of patients that have not yet been recorded in the scientific literature. This will be part of the first analysis of clinical treatment data. An expansion of the KnorpelRegister DGOU to patients with cartilage defects of the ankle and hip joints is already decided upon and initialised.

[Focal cartilage defects within the medial knee compartment. predictors for osteoarthritis progression]. / Fokale Knorpelschäden des medialen Gelenkkompartiments: Prädiktoren für die Progression der Kniearthrose.

AIM: The aim of this study was to evaluate the progression of osteoarthritis (end-stage disease with a requirement for arthroplasty) in patients with focal cartilage defects of the medial knee compartment. MATERIAL AND METHODS: Patients (n = 115) with focal cartilage lesions of the medial knee compartment underwent arthroscopy. The follow-up was performed 10 years after the operation to determine the rate of arthroplasty conversion and to evaluate associated factors. RESULTS: In a total of 35 cases an arthroplasty was needed (30.4 %). The mean survival to arthroplasty was 93.2 (95 % CI 85.4-109.0) months. Cartilage defects within the femur and cartilage lesions within the patella and the lateral did not influence the OA progression. Among the significant risk factors for OA progression were higher patient age, female gender, overweight or obesity and severity of meniscal damage. The most important risk factor was the occurrence and the extent of tibial cartilage defects. CONCLUSIONS: In the natural course, about 30 % of patients with focal cartilage defects of the medial knee compartment undergo rapid OA progression (arthroplasty as end-stage of the disease). There are general risk factors (age, female gender and obesity) but also local risk factors. Furthermore, tibial defects and the extent of meniscus loss influence the outcome significantly. These general and local factors should be more carefully estimated or addressed in future clinical and scientific work.

[The effect of arthroscopic debridement and conservative treatment in knee osteoarthritis: Results of a 5-year follow-up and literature review]. / Die Behandlung moderater Kniegelenksarthrosen durch arthroskopisches Gelenkdebridement: 5-Jahres-Ergebnisse und systematisches Review.

PURPOSE: This study is aimed to compare the effects of arthroscopic joint debridement over a 5-year period in a clearly defined patient population (only grade III knee osteoarthritis, history < 2 years). MATERIAL AND METHODS: A total of 96 patients (50 male and 46 female) underwent arthroscopic knee debridement for knee OA. The main criteria for inclusion were osteoarthritis grade III (Kellgren-Lawrence score) and a maximal history of 2 years. RESULTS: The subjective complaints and the knee-related quality of life were estimated by the KOOS (knee injury and osteoarthritis outcome score). The score increased significantly within the 1 to 3 rd year post operation. After this interval the mean points of the score declined. But after 5 years the KOOS was higher in comparison to the baseline dates. Patients who had undergone conservative treatment at baseline had a significantly different KOOS than patients in the arthroscopy group. Over time, patients in the arthroscopy group had fewer complaints than patients in the conservative treatment group. In both groups, the results decreased over time. A total of 17 patients (17.2 %) needed a conversion to total endoprothetic replacement. The mean time-interval between index operation and conversion was 56.6 (95 % CI 54.4 - 58.4) months. CONCLUSIONS: In middle stages of knee OA, arthroscopic joint debridement can effectively reduce subjective complaints. Because this treatment does not stop the process of OA, the improvements decrease over time.

[Prevalence and distribution of knee cartilage lesions in sportspersons and non-sportspersons: results of a retrospective arthroscopic study]. / Häufigkeit und Verteilung von Knorpelschäden des Kniegelenks bei Sportlern und Nicht-Sportlern: Ergebnisse einer retrospektiven arthroskopischen Studie.

AIM: This study was aimed to evaluate the correlation between sports activity and frequency and grad of non-traumatic knee cartilage lesions. METHODS: A total of 868 patients (469 male and 399 female) who were suffering from knee pain (> 3 months) had undergone knee arthroscopy. The mean duration of history was 11.4 ± 11.5 (3 - 48) months. Criteria for exclusion were major knee injuries (e. g., ACL injuries). All cartilage lesions were classified according to the ICRS (International Cartilage Repair Society) guidelines and summarised with the semiquantitative WOAKS (Whole Organ Arthroscopic Knee Score). RESULTS: There was a significant correlation between cartilage degeneration and age. Older female patients (63 to 85 years) demonstrated higher knee degenerations than male patients. The grade cartilage degeneration was higher in non-sportspersons (WOAKS = 13.5 ± 13.8) than in sportspersons (WOAKS = 7.1 ± 5.3), p < 0.001. Only in younger patients (17 to 34 years) was there no difference in the frequency of cartilage lesions in correlation to sports activity. A high-pivoting sport was significantly more frequently associated with cartilage degeneration in comparison to low-pivoting sports. Cartilage lesions most frequently occur within the mean bearing zones of the medial knee compartment. With regard to sports activity, no differences were observed in the distribution of cartilage lesions. CONCLUSIONS: Sportspersons who suffer from knee pain without injury have significantly less cartilage lesions or, respectively, severe cartilage defects. Cartilage lesions mostly occur within the medial knee compartment without correlation to sports activity and sport type. Patients who are performing "high-pivoting" sports more frequently are suffering from severe cartilage lesions than "low-pivoting" sportspersons. For a final epidemiological estimation of any correlations between sports and cartilage damage, longitudinal MRI studies are needed.

[Evaluation of cartilage degeneration by near infrared spectroscopy (NIRS): methodical description and systematic literature review]. / Bestimmung des Degenerationsgrads am hyalinen Gelenkknorpel durch Nah-Infrarot-Spektroskopie (NIRS): Methodenbeschreibung und Literaturübersicht.

Damage to hyaline cartilage is the most important pathophysiological tool in the development of osteoarthritis. Cartilage lesions are the most frequent pathological findings during arthroscopic operations. Arthroscopies as well as magnetic resonance tomography are gold standards for detection of cartilage lesions. But the arthroscopic evaluation of cartilage lesions is descriptive and subjective only. The surgeon is able to differentiate between intact cartilage surface, softening, superficial or deep fissure or flake and finally a complete defect. In routine arthroscopy the grading mostly is made by use of different scores [e.g. ICRS (International Cartilage Repair Society), Outerbridge, Insall, Jäger-Wirth or others]. Because the arthroscopic evaluation is subjective the reliability of this method is poor. Spectroscopic methods are established for evaluation of different tissue diseases in different indications. NIRS (near infrared spectroscopy) has become an important method for medical diagnostics in the last years. NIR is very energy-rich and suitable for glass fibre transport without relevant reduction. Insofar this technology may be ideal for endoscopic procedures. Our systematic literature review reveals that NIRS is a sufficient method for an objective diagnosis of cartilage lesions. In the current work we demonstrate an NIRS-based device for intraoperative, real-time cartilage evaluation. Furthermore, we discuss the possible clinical consequences from such measurements.

[Therapy of acute ankle sprain: one-year results of primary conservative treatment]. / Therapie der fibulotalaren Bandverletzung: Ein-Jahres-Ergebnisse nach primär konservativer Behandlung.

INTRODUCTION AND AIM: Ankle sprains (supination-eversion injury) have a high incidence. Conservative treatment is generally the method of choice. This study is intended to evaluate the 1-year results of a standardised treatment protocol. MATERIAL AND METHODS: A total of 416 patients who had suffered an ankle sprain were included into this study. All of them had undergone primary conservative treatment. A total of 66 of them (15.9 %) had undergone operative treatment within one year after injury. The indications for operation were persistent pain, swelling or persistent instability. In 33 patients an arthroscopy for evaluation of the joint and debridement was used. In the case of a persistent instability 22 ligament augmentations (Kuner periostal flap) and 11 peroneus tenodesis (Watson-Jones) were performed. The evaluation was done by using the AOFAS score ("Ankle Hindfoot Scale" of the American Orthopedic Foot and Ankle Society). RESULTS: A 1-year follow-up was possible in 96.4 % of the patients. The mean AOFAS score was 77.1 ± 10.5 points after conservative treatment. Those patients who needed an arthroscopic debridement had a slightly better outcome (AOFAS score 79.5 ± 10.2 points). Patients who had undergone stabilisation operations tended to have the best outcome (p = 0.093). The AOFAS score was 79.6 ± 15.4 points in patients after periostal flap augmentation, respectively, 83.0 ± 7.4 points after peroneus tenodesis. CONCLUSIONS: The results confirm the benefit of conservative treatment in acute ankle sprain. Even so about 15 - 20 % of the patients still suffer from persistent pain, swelling or instability. The indication for operative intervention should be made relatively broadly. Most of these patients profit from the operation. Above all, after ankle sprain patients need a continuous re-evaluation by a specialised centre during the first post-injury year.

[Knee cartilage lesions and occupational load. Results of an arthroscopic study]. / Knorpelschaden des Kniegelenks und berufliche Belastung. Ergebnisse einer arthroskopischen Studie.

AIM: Numerous epidemiological studies have suggested a relationship between knee osteoarthritis and occupational load or, respectively, a kneeling or squatting position at work. Cartilage breakdown was clearly identified as the main mechanism of the osteoarthritic process. This arthroscopic study was aimed to evaluate the relationship between frequency and grade of knee cartilage damage compared with occupational load. It was hypothesised that heavy work conditions cause higher cartilage degeneration in diverse age groups. Furthermore, it was suggested that kneeling or squatting work positions (analogous to the BK 2112) produce more severe cartilage damage or other distributions thereof compared with patients in low knee-loading professions. METHODS: A total of 1199 patients with knee pain (history of 3 months or more) underwent arthroscopic operations. Cartilage lesions were classified according to the ICRS (International Cartilage Repair Society) protocol. The grading of joint degeneration was quantified by using the WOAKS (whole organ arthroscopic knee score). Patients were divided into 5 age groups (24-39-51-64-75 years) by analysis of cluster centres. RESULTS: In 80.6% (n = 1086) the preoperative radiography suggested signs of a knee osteoarthritis. There was a range from grade I to grade III osteoarthritis according to the Kellgren-Lawrence score. Older female patients had knee osteoarthritis significantly (p = 0.027) more frequently. The grade of osteoarthritis correlated significantly with the patients' age (p > 0.001). The mean WOAKS was 16.6 +/- 13.7 points. There was a continuous increase of WOAKS from 8.2 +/- 5.1 in 24-year-old patients to 24.2 +/- 16.3 points in 75-year-old patients (p < 0.001). In about half of the cases cartilage lesions within the patella and trochlea were evaluated. Most frequently we recorded cartilage lesions within the mean bearing zone of the medial femoral condyle (96.2%) and the medial tibia (57.7)%. Only about a third of our patients suffered from cartilage lesions within the mean bearing zone of the lateral condyle and tibia. The frequency of cartilage lesions and the severity of the lesions grade was significantly less within the non-loaded margin of the surfaces. In 45 knees (3.8%) we found intraarticular osteophytes located: medial (n = 9) and lateral (n = 3) patella margin, intracondylar notch (n = 12), medial tibia (n = 9) and lateral margin of the lateral tibia (n = 4), lateral femoral condyle at the intersection to the lateral trochlea margin (n = 3). The occurrence of osteophytes correlated with the patients' age and the radiological grade of the osteoarthritis. There were no differences with respect to the profession within the age groups. In the non-adjusted WOAKS, patients with hard knee-loading work had a WOAKS of 16.8 +/- 13.9 points and patients with soft work a score of 17.2 +/- 14.3 points (p = 0.583). Differences in the frequency of cartilage distributions within the judged regions of the knee with respect to professional burden were also not evaluated. The same held for the frequency of intraarticular osteophytes. CONCLUSION: Despite there is a known relation between occupational load and knee osteoarthritis no relation to cartilage degeneration was found in our arthroscopic investigation. For better understanding of work-related knee osteoarthritis prospective studies are needed urgently.

Initial load-to-failure and failure analysis in single- and double-row repair techniques for rotator cuff repair.

AIM: This experimental study aimed to compare the load-to-failure rate and stiffness of single- versus double-row suture techniques for repairing rotator cuff lesions using two different suture materials. Additionally, the mode of failure of each repair was evaluated. METHOD: In 32 sheep shoulders, a standardized tear of the infraspinatus tendon was created. Then, n = 8 specimen were randomized to four repair methods: (1) Double-row Anchor Ethibond coupled with polyester sutures, USP No. 2; (2) Double-Row Anchor HiFi with polyblend polyethylene sutures, USP No. 2; (3) Single-Row Anchor Ethibond coupled with braided polyester sutures, USP No. 2; and (4) Single-Row Anchor HiFi with braided polyblend polyethylene sutures, USP No. 2. Arthroscopic Mason-Allen stitches were placed (single-row) and combined with medial horizontal mattress stitches (double-row). All specimens were loaded to failure at a constant displacement rate on a material testing machine. RESULTS: Group 4 showed lowest load-to-failure result with 155.7 +/- 31.1 N compared to group 1 (293.4 +/- 16.1 N) and group 2 (397.7 +/- 7.4 N) (P < 0.001). Stiffness was highest in group 2 (162 +/- 7.3 N/mm) and lowest in group 4 (84.4 +/- 19.9 mm) (P < 0.001). In group 4, the main cause of failure was due to the suture cutting through the tendon (n = 6), a failure case observed in only n = 1 specimen in group 2 (P < 0.001). CONCLUSIONS: A double-row technique combined with arthroscopic Mason-Allen/horizontal mattress stitches provides high initial failure strength and may minimize the risk of the polyethylene sutures cutting through the tendon in rotator cuff repair when a single load force is used.

Comparative evaluation of the tendon-bone interface contact pressure in different single- versus double-row suture anchor repair techniques.

The aim of the study was to evaluate the time zero contact pressure over a defined rotator cuff footprint using different repair and stitch techniques in an established sheep model. Forty fresh-frozen sheep shoulders were randomly assigned to five repair groups: single-row repair using simple stitches (SRA-s), single-row repair using horizontal mattress stitches (SRA-m), and single-row repair using arthroscopic Mason-Allen stitches (SRA-ama). Double-row repair was either performed with a combination of simple and horizontal mattress stitches (DRA-sm) or with arthroscopic Mason-Allen/horizontal mattress stitches (DRA-amam). Investigations were performed using a pressure-sensitive film system. The average contact pressure and pressure pattern were measured for each group. Contact pressure was lowest in SRA-m followed by SRA-s. SRA-ama showed highest contact pressure of all single-row treatment groups (P < 0.05). DRA-amam presented the highest overall contact pressure (P < 0.05), whereas DRA-sm exerted contact pressure equal to that of SRA-ama. Both double-row techniques showed the most expanded pressure pattern. Average contact pressures for the more complex single- and double-row techniques utilizing arthroscopic Mason-Allen stitches were greater than were those of the repair techniques utilizing simple and horizontal mattress stitches. However, the contact pattern between the anchors could be increased by using the double-row technique, resulting in more footprint coverage compared to patterns utilizing the single-row techniques. These results support the use of the more complex arthroscopic Mason-Allen stitches and may improve the environment for healing of the repaired rotator cuff tendon.

Biomechanical characteristics of single-row repair in comparison to double-row repair with consideration of the suture configuration and suture material.

The aim of the study was to evaluate the time zero mechanical properties of single- versus double-row configuration for rotator cuff repair in an animal model with consideration of the stitch technique and suture material. Thirty-two fresh-frozen sheep shoulders were randomly assigned to four repair groups: suture anchor single-row repair coupled with (1) braided, nonabsorbable polyester suture sized USP No. 2 (SRAE) or (2) braided polyblend polyethylene suture sized No. 2 (SRAH). The double-row repair was coupled with (3) USP No. 2 (DRAE) or (4) braided polyblend polyethylene suture No. 2 (DRAH). Arthroscopic Mason-Allen stitches were used (single-row) and combined with medial horizontal mattress stitches (double-row). Shoulders were cyclically loaded from 10 to 180 N. Displacement to gap formation of 5- and 10-mm at the repair site, cycles to failure, and the mode of failure were determined. The ultimate tensile strength was verified in specimens that resisted to 3,000 cycles. DRAE and DRAH had a lower frequency of 5- (P = 0.135) and 10-mm gap formation (P = 0.135). All DRAE and DRAH resisted 3,000 cycles while only three SRAE and one SRAH resisted 3,000 cycles (P < 0.001). The ultimate tensile strength in double-row specimens was significantly higher than in others (P < 0.001). There was no significant variation in using different suture material (P > 0.05). Double-row suture anchor repair with arthroscopic Mason-Allen/medial mattress stitches provides initial strength superior to single-row repair with arthroscopic Mason-Allen stitches under isometric cyclic loading as well as under ultimate loading conditions. Our results support the concept of double-row fixation with arthroscopic Mason-Allen/medial mattress stitches in rotator cuff tears with improvement of initial fixation strength and ultimate tensile load. Use of new polyblend polyethylene suture material seems not to increase the initial biomechanical aspects of the repair construct.

[Evaluation of cartilage defects in the knee: validity of clinical, magnetic-resonance-imaging and radiological findings compared with arthroscopy]. / Diagnostik von Knorpelschäden des Kniegelenks: Validität der klinischen, radiologischen und kernspintomographischen Diagnostik im Vergleich zur Arthroskopie.

BACKGROUND: The study was aimed to evaluate the validity of clinical, radiological and MRI examination for cartilage defects of the knee compared with arthroscopic finding. METHODS: Seven-hundred seventy-two patients who were suffering from knee pain over more than 3 months were evaluated clinical (grinding-sign) and with radiography and magnetic resonance imaging (MRI) and subsequent arthroscopy. RESULTS: The grinding sign had a sensitivity of 0.39. The association of a positive grinding test with high grade cartilage defects was significant (p<0.000). In 97.4% an intact chondral surface correlated with a normal radiological finding. Subchondral sclerosis, exophytes and a joint space narrowing was significantly associated with high grade cartilage defects (p<0.000). The accuracy of MRI was 59.5%. The MRI resulted in an overestimation in 36.6% and an underestimation in 3.9%. False-positive results were significant more often assessed in low-grade cartilage defects (p<0.000). CONCLUSIONS: Clinical signs, x-ray imaging and MRI correlate with arthroscopic findings in cases of deep cartilage lesions. In intact or low-grade degenerated cartilage often results an overestimating of these findings.

Functional outcome and general health status in patients after arthroscopic release in adhesive capsulitis.

Frozen shoulder is said to be a self-limiting entity but full recovery often takes more than 2 years. For that, most patients are unwilling to tolerate painful restriction while awaiting resolution. We prospectively investigated 30 patients (16 women, 14 men) for the outcome of arthroscopic capsular release in idiopathic frozen shoulder. Results were determined by the assessment of subjective and objective parameters to estimate both shoulder function and general health status. Symptoms persisted without improvement for a minimum of 6 months of conservative treatment. Preoperative average American shoulder and elbow surgeons score (ASES) was 35, visual analog scale (VAS) to measure pain was 7, and simple shoulder test (SST) was 4. Mean scores of the physical component of SF-36 were considerably reduced. Mean forward elevation was 85 degrees , average abduction was 70 degrees , mean internal rotation was 15 degrees , and mean external rotation was 10 degrees . Patients were followed-up at 6 weeks, 3, 6, 12 months and by a mean of 36 months. Range of motion for all planes improved (P < 0.05). Median VAS reduced to 2, average ASES increased to 91, and SST enhanced to a mean of 10 (P < 0.05). We stated improvement of the physical components in the SF-36 questionnaire in particular bodily pain and the role-physical score. There were no significant differences between the measurements in the early postoperative phase compared to the mid-term follow-up (P > 0.05). Our results demonstrate that arthroscopic release of refractory idiopathic frozen shoulder combined with a gentle manipulation provides reliable expectations for improvement in both clinical and general health status for most patients. We recommend the use of a limb-specific and a general-health-status questionnaire to conclude the benefit of the surgical intervention and contribute the optimization of a therapy concept more effectively.

Factors that influence high tibial osteotomy results in patients with medial gonarthritis: a score to predict the results.

OBJECTIVE: High tibial osteotomy (HTO) for the treatment of unicompartmental knee osteoarthritis in the presence of axial malalignment is recognized as an effective treatment for young and active patients. The aim of this study was to identify HTO prognostic factors. METHODS: A total of 94 patients who had undergone HTO with additive arthroscopy were scored using the "knee injury and osteoarthritis outcome score" (KOOS). A KOOS of less than 114 points was judged as a poor outcome. RESULTS: A total of 84 patients were available for follow-up after a time-interval of 45.9+/-7.6 (range 34-60) months. The KOOS increased from 46.1+/-11.1 to 120.3+/-40.8. The preoperative varus angle in all patients was 7.5 degrees +/-1.9 (range 5-14 degrees ). In follow-up the patients had a mean valgus angle of 3.7 degrees +/-2.5. Twenty-three patients (27.4%) had suffered a loss of correction (0.8 degrees , range 0-2 degrees ). A loss of correction correlated with a minor result in tendency. A total of 25 patients (29.8%) had a poor KOOS. Factors associated with a poor HTO outcome were a patient history of more than 24 months, a preoperative KOOS>50 points, obesity, and smoking. However, the results were also influenced by radiological findings, such as medial tibial exophyte, a medial joint space width of less than 5mm, and intraarticular damage, such as a degree IV cartilage defect of the tibia. Gender was also a minor prognostic factor. Patient's age and the event of prior surgery did not influence the outcome. CONCLUSION: This study identified relevant factors that significantly influenced HTO results. It was possible to create a "predictive score" for HTO patients. Patients with more than 4 of the poor prognostic factors should chose primary arthroplasty.

Arthroscopic debridement of irreparable massive rotator cuff tears--a comparison of debridement alone and combined procedure with biceps tenotomy.

The goal of the study was to compare the results of arthroscopic debridement in massive, irreparable rotator cuff tears with and without tenotomy of the long head of the biceps (LHB). We evaluated 41 patients who were treated by a single surgeon for massive, irreparable rotator cuff tears either by arthroscopic debridement alone (24 patients) or with additional tenotomy of LHB (17 patients). The mean age was 67 years (range: 61 to 82 years) and the average follow-up was 31 months (range: 24 to 48 months). There was no significant difference between the two groups in age, gender, pain, function, and follow-up. All patients had significant disabling pain weakness preoperatively. Assessments were made using the Constant score. The average Constant score for the group without LHB tenotomy improved from a mean of 39 points (range: 19 to 54 points) preoperatively to a mean of 67 points (range: 41 to 87 points) and for the group with additional LHB tenotomy from a mean of 41 points (range: 16 to 54 points) preoperatively to a mean of 69 points (range: 49 to 87 points) at the time of follow-up. The radiological study showed no significant narrowing of the subacromial space. No statistical significance (P > .05) was found between the two groups. However, patients with additional LHB tenotomy had a longer duration of postoperative pain relief, but final pain score difference was not statistically significant. There was no complication related to the procedure. Arthroscopic débridement of massive, irreparable rotator cuff tears provides reliable expectation for improvement in function, decrease in pain, and improvement in shoulder scores for most patients. Additional LHB tenotomy did not significantly influence the postoperative results at the latest follow-up. In our series we noted no significant humeral head migration or developing rotator cuff arthropathy.