Biomechanical evaluation of suture-tendon interface and tissue holding of three suture configurations in torn and degenerated versus intact human rotator cuffs.

PURPOSE: The purpose of this study was to biomechanically evaluate suture-tendon interface and tissue holding of three sutures in torn and degenerated versus intact human rotator cuffs. METHODS: Sixty-three human rotator cuff tendons were divided into torn degenerated group (TDG), n = 21 and intact group (IG), n = 42. Ultimate tension load (UTL) and cyclic loading were tested for three arthroscopic sutures: simple, horizontal, and massive cuff sutures (MCS). RESULTS: Ultimate tension load was significantly higher (p < 0.05) for the MCS (194 ± 68 N) in comparison with the simple (105 ± 48 N) and horizontal sutures (141 ± 49 N) in IG. In TDG, UTL was not significantly higher (n.s.) for MCS (118 ± 49 N), simple (79 ± 30 N), and horizontal sutures (107 ± 28 N) in comparison with IG. MCS (118 ± 49 N) showed no significantly superior UTL in comparison with the simple and horizontal sutures in the TDG. MCA elongation was 0.6 ± 0.7 mm in the IG and 1.3 ± 0.7 mm in the TDG, while horizontal suture elongation was 0.7 ± 0.4 mm in the IG and 1.3 ± 0.5 mm in the TDG. Simple suture elongation was 1.1 ± 0.5 mm in the IG and 1.6 ± 0.7 mm in the TDG. CONCLUSION: Human torn and degenerated rotator cuffs have poor tissue quality, significantly lower UTL and higher cyclic elongation in comparison with intact cuffs regardless of the type of suture used for repair, which invites the need for repair techniques that grasps greater tissue volume in addition to augmentation techniques. CLINICAL RELEVANCE: Clinicians better use repair techniques that grasp greater tissue volume (e.g. MCS, modified Mason-Allen cross bridge, double-row cross bridge, etc.) when repairing the torn and degenerated rotator cuffs.

Resection arthroplasty with and without capsular interposition for treatment of severe hallux rigidus.

Resection arthroplasty-known as the Keller procedure-is used for the treatment of severe hallux rigidus. As a modification of this procedure, resection arthroplasty is combined with cheilectomy and interposition of the dorsal capsule and extensor hallucis brevis tendon, which are then sutured to the flexor hallucis brevis tendon on the plantar side of the joint (capsular interposition arthroplasty). In this study the clinical and radiological outcome of 22 feet treated by interposition arthroplasty were investigated and compared with those of 30 feet on which the Keller procedure was performed. The mean follow-up period was 15 months. No statistically significant difference was found between either group concerning patient satisfaction, clinical outcome and increase in range of motion of the first metatarsophalangeal joint. At follow-up, patients who had undergone interposition arthroplasty did not show statistically significantly better American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores than those of the Keller procedure group. A high rate of osteonecrosis of the first metatarsal head was found in both groups. These radiological findings did not correlate with the clinical outcome at follow-up. In conclusion, no significant benefit in clinical or radiological outcome was found for capsular interposition arthroplasty compared with the Keller procedure.

Tapping test in patients with painful bone marrow edema of the knee.

BACKGROUND: Although bone marrow edema (BME) of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated. We hypothesized that a mallet test would be useful as a diagnostic aid and a screening tool. METHODS: Seventy patients (36 female, 34 male) were investigated in this controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS). RESULTS: The VAS score was 3.7 (+/-2.1 cm) for quadrants affected by BME (group 1), 1.59 (+/-1.44) in nonaffected quadrants of the knee affected by BME (group 1) and, 0.85 (+/-0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (P<0.0001) and the affected quadrant (P<0.0001 for the medial femoral condyle and the medial femoral plateau). A threshold value of VAS 2.0 for a tapping test to be positive in the distinction of BME affected quadrants of group 1 and all quadrants of group 2 sensitivity was 90.4%, specificity 83.7%, positive predictive value 73.4%, and negative predictive value 94.6% was determined. CONCLUSION: The tapping test is a good screening instrument to diagnose BME in the knee.

Deformity correction in children with hereditary hypophosphatemic rickets.

UNLABELLED: X-linked hereditary hypophosphatemic rickets can induce various multiplanar deformities of the lower limb. We evaluated our ability to correct these deformities and assessed complications and recurrence rates in 10 children (eight girls and a pair of twin boys) followed from early childhood to skeletal maturity. We performed 37 corrective operations in 10 children. Depending on the patient's age, external fixation was used in 53 segments: Kirschner wires in 18, DynaFix in three, the Taylor Spatial Frame device in 13, and the Ilizarov device in 19. Internal fixation with intramedullary nailing was performed in 12. After bone consolidation, we radiographically determined the mechanical axis at an average distance of 0.5 cm medial to the center of the knee. The average mechanical lateral distal femoral angle was 85 degrees (range, 83 degrees-92 degrees) and the average mechanical medial proximal tibial angle was 91 degrees (range, 85 degrees-92 degrees). Deviation of the mechanical axis and knee orientation lines was increased at the followups conducted during a period of 5 to 12 months. Additional followups revealed a recurrence rate of 90% after the first corrective procedure and 60% after a second procedure. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Natural course of intra-articular shifting bone marrow edema syndrome of the knee.

BACKGROUND: Intra-articular shift (migration) of bone marrow edema syndrome (BMES) is a very rare disease. Only a few cases have been reported thus far. The condition may cause the clinician to suspect an aggressive disease. METHODS: We reviewed eight patients (four women and four men) with unilateral BMES located in the knee. The patients were aged 39 to 56 years (mean, 49.2 years). In all patients, bone marrow edema (BME) initially observed on magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or the adjacent bone. Seven patients were given conservative therapy, including limited weight-bearing, for a period of three weeks after the initial detection of BMES, whereas one patient underwent surgical core decompression twice. RESULTS: MR imaging showed complete restitution in 6 cases and a small residual edema in one case. A final control MR could not be obtained for one patient, who had no pain. A further patient had an avascular necrosis of the contralateral hip after 16 months. Improvement on MR imaging was correlated with the clinical outcome in all cases. All patients became asymptomatic after a mean period of 9 months (6-11). INTERPRETATION: Intra-articular shifting BMES is a very rare condition. As the disease is self-limiting, conservative therapy may be recommended.

MRI-demonstrated outcome of subchondral stress fractures of the knee after treatment with iloprost or tramadol: observations in 14 patients.

OBJECTIVE: To investigate the outcome of subchondral stress fractures (SSF) of the knee after treatment with the prostacyclin analogue Iloprost or the opioid analgesic Tramadol. DESIGN: Case series/retrospective review. SETTING: Tertiary care center. PATIENTS: Fourteen patients with at least a single subchondral stress fracture of the knee, surrounded by bone marrow edema, visible on T1-weighted and short tau inversion recovery magnetic resonance images. INTERVENTIONS: Nine patients had been treated with oral Iloprost (group 1; 11 SSF) and 5 patients with Tramadol (group 2; 5 SSF) for 4 weeks in the course of a double-blind, randomized clinical trial. MR images were obtained at baseline (1 day before the start of treatment), after 3 months, and after 1 year. MAIN OUTCOME VARIABLES: SSF volumes and their rates of change between baseline and follow-up examinations, as determined on T1-weighted images by computer-assisted quantification. RESULTS: After three months, the SSF volumes had decreased by a median of 42.2% in group 1 and increased by a median of 2.2% in group 2 (P = 0.008). After 1 year, the median decrease in SSF volumes was 100.0% in group 1 and 65.7% in group 2 (P = 0.017). CONCLUSION: This small case series suggests that healing of SSF is more pronounced after Iloprost treatment.

Bone marrow edema syndrome of the femoral head: treatment with the prostacyclin analogue iloprost vs. core decompression: an MRI-controlled study.

BACKGROUND: The purpose of this study was to assess the efficacy of the vasoactive drug iloprost in Bone Marrow Edema Syndrome (BMES) and to compare it to the results of a control group treated by core decompression. PATIENTS AND METHODS: 38 hips (36 patients) with BMES in the femoral head were investigated. In group A, 18 hips (17 patients; mean age 49 years) were treated with iloprost, a vasoactive drug that dilates arterioles and venules, reduces capillary permeability and suppresses platelet aggregation. The therapy comprised a series of five infusions with 20 microg iloprost over 6 hours on 5 consecutive days. Weight bearing was reduced for up to 3 weeks, depending on the severity of symptoms. In group B, 20 hips (19 patients; mean age 41 years) underwent surgical core decompression of the femoral head followed by 6 weeks of partial weight bearing. Both groups were evaluated clinically, radiographically and by MRI. RESULTS: In group A, one patient had to discontinue therapy on the first day because of severe headache. In the remaining patients the Harris Hip Score (HHS) improved from a mean of 64.7 points (range 44-89) before therapy to 97.0 points (83-100) after 3 months. MRI controls showed complete remission in all hips. In group B, the preoperative HHS improved from 53.7 points (31-82) to 95.1 points (39-100) after 3 months. MRI controls showed complete remission of BMES in 14 hips, residual focal bone marrow edema in four hips and a small osteonecrotic area in two hips. In both groups the high level of clinical recovery was maintained at the last examination after a mean follow up of 11 months in group A and 12 months in group B. CONCLUSION: The parenteral application of iloprost can achieve equal or better results in the treatment of bone marrow edema syndrome of the hip compared to core decompression.

MRI-controlled analysis of 104 patients with painful bone marrow edema in different joint localizations treated with the prostacyclin analogue iloprost.

BACKGROUND: Bone marrow edema (BME) is a common cause of pain of the musculoskeletal system. The aim of the study was to assess the efficacy of iloprost in the treatment of BME of different localizations and etiologies. PATIENTS AND METHODS: We reviewed 104 patients (54 male, 50 female) with BME. Their mean age was 52.8 +/- 14.7 years. BME was located 50 times in the knee, 19 times in the talus, 18 times in the femoral head and 17 times in other bones. Patients were allocated to three distinct etiological groups: 27 cases were estimated to have idiopathic BME, 16 post-traumatic BME and the other 61 BME secondary to activated osteoarthritis or mechanical stress. Therapy consisted of a series of five iloprost infusions with either 20, 25 or 50 microg of iloprost given over 6 hours on 5 consecutive days each. RESULTS: At the clinical follow-up four months after therapy, the pain level of the 104 patients at rest had diminished by a mean of 73% (p<0.0001): 64% of patients reported a reduction, 34% no change and 2% an increase in pain at rest. Pain under stress decreased by a mean of 59%, (p<0.0001): 76% of patients had less pain during activity, 22% no change from baseline and 2% an increased pain level. On MRI, 65% had significant reduction of BME size or complete normalization and 20% showed no change. Worsening of the MRI pattern was found in 2%. 13% were lost to MRI follow-up. Side effects were significantly reduced by lowering the daily dose from 50 to 20 microg, without impairment of therapeutic effect. CONCLUSION: The authors conclude that the use of parenteral iloprost might be a viable method in the treatment of BME of different etiologies.

Bone marrow edema syndrome in postpartal women: treatment with iloprost.

Bone marrow edema syndrome of the femoral head in pregnant women is a rare disease resulting in disabling coxalgia, beginning in the last 3 months of pregnancy and persisting for several months after parturition. The parenteral administration of the vasoactive drug iloprost constitutes a new approach to the treatment of painful bone marrow edema syndrome of the hip of pregnant women. Six postpartal women (8 hips) with bone marrow edema syndrome of the femoral head were treated with iloprost followed by 3 weeks of partial weight-bearing. Relief from pain, restoration of functional capacity, and normalization of the MRI signal pattern were rapidly achieved, thus avoiding the need for surgical intervention. As the substance is contraindicated in pregnancy, therapy may begin only some days after parturition, with a short discontinuation in breastfeeding.

Outcome of painful bone marrow edema of the femoral head following treatment with parenteral iloprost.

BACKGROUND: Bone marrow edema (BME) is a common cause of hip pain. The aim of the study was to assess the efficacy of the vasoactive drug iloprost in the treatment of BME of femoral head. MATERIALS AND METHODS: We reviewed 27 patients (19 male, 8 female) with BME of the femoral head. Their mean age was 53.7 +/- 10.8 years. All patients were treated with iloprost, a vasoactive drug that dilates arterioles and venules, reduces capillary permeability and suppresses platelet aggregation. The therapy comprised a series of five infusions with 20 to 50 mug iloprost over 6 h on 5 consecutive days each. Weight bearing was reduced for up to 3 weeks, depending on the severity of symptoms. Pain at rest as well as under stress was assessed with a semi quantitative scale from before and 4 months after therapy. MRI investigations were done before and repeated 4 months after therapy. RESULTS: At the clinical follow up of four months after therapy, the pain level at rest had diminished by a mean of 58.3% (P < 0.0001). Pain under stress decreased by a mean of 41.9% (P < 0.0001). On MRI, 20 patients had a significant reduction of BME size or complete normalization and 4 showed no change. Worsening of the MRI pattern was found in 3 patients. CONCLUSION: The authors conclude that the use of parenteral iloprost might be a viable method in the treatment of BME of femoral head.

Computer-assisted quantitative analysis of bone marrow edema of the knee: initial experience with a new method.

OBJECTIVE: The purpose of this study was to describe a largely observer-independent computer-assisted method for accurate quantitative analysis of bone marrow edema. MATERIALS AND METHODS: Ten patients with bone marrow edema of the knee were included in the study. Coronal STIR images of the affected knees were obtained using a 1.0-T MR scanner. Size and signal intensity of the bone marrow edema were assessed on the basis of gray-scale value analysis and calculation of a threshold value for differentiating normal and edematous bone marrow. All measurements were carried out three times for statistical analysis. RESULTS: The intraobserver coefficient of variation was 0.89% for the volume and 0.94% for the signal intensity of the bone marrow edema, showing the small impact of manual interference on results produced with this method. CONCLUSION: A computer-assisted method for quantification of bone marrow edema has been described. Intraobserver variation was very low, indicating excellent reproducibility of results. Although the method is too time-consuming for clinical use, it is recommended for research purposes.