Spontaneous healing of acute ACL ruptures: rate, prognostic factors and short-term outcome.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction is considered the first line treatment in ACL rupture. However, some patients return to high intensity sport activities and show a normal knee function without ACL reconstruction. Therefore, aim of this study was to evaluate the rate and prognostic factors of spontaneous healing in patients with ACL rupture and the short-term functional outcome. METHODS: The rate, prognostic factors and short-term functional results of spontaneous healing in patients with ACL rupture were evaluated in 381 patients. Morphology of ACL rupture and extent of posterior tibial slope (PTS) were classified by MR- and x-ray imaging. In patients with normal knee stability in anesthesia examination and healed ACL during the arthroscopy 6 weeks after trauma ACL reconstruction was canceled. IKDC -, Tegner Activity Score, KT 1000 testing and radiological characteristics were collected 12 months postoperatively in these patients. RESULTS: 14.17% of the patients with ACL rupture showed a spontaneous healing after 6 weeks. Femoral ACL-rupture (p < 0.02) with integrity of ligament stump > 50% (p < 0.001), without bundle separation (p < 0.001) and decreased PTS (p < 0.001) was found significantly more often in patients with a spontaneous healed ACL. The average IKDC score was high at 84,63 in patients with healed ACL at 1 year follow-up, but KT 1000 testing was inferior compared to non-injured side. CONCLUSION: Spontaneous healing of a ruptured ACL happened in 14% of the patients. Especially in low-demand patients with femoral single bundle lesions without increased posterior tibial slope delayed ACL surgery should be considered to await the possibility for potential spontaneous ACL healing.

Deactivation of cardiovascular implantable electronic devices in patients nearing end of life : Reality or only recommendation?

BACKGROUND: Current guidelines recommend considering deactivation of cardiac implantable electronic devices (CIEDs) in patients nearing death. We evaluated the implementation of this recommendation in unselected deceased individuals with CIEDs. METHODS: Over a 7-month period in 2016, all deceased persons taken to the Rostock crematorium were prospectively screened for CIEDs and these were interrogated in situ. Pacing rate, pacing mode, and lead output were documented as well as patient data including location and time of death. In implantable cardioverter-defibrillators (ICDs), tachycardia therapy adjustment and occurrence of shocks 24 h prior to death were also recorded. RESULTS: We examined 2297 subjects, of whom 154 (6.7%) had CIEDs. Of these subjects, 125 (100%) pacemakers (PMs) and 27 (96.4%) ICDs were eligible for analysis. Death in persons with ICDs occurred most frequently in hospital (55.6%), while this was less frequently the case for individuals with PMs (43.2%). Furthermore, 33.3% of subjects with ICDs and 18.5% with PMs died in palliative care units (PCU). Shock therapies were switched off in three (60%) individuals with ICDs who died in the PCU, whereas antibradycardia therapy was not withdrawn in any PM patient in the PCU. Therapy withdrawal occurred in two patients with PMs (1.3%) who died in hospital. Patients with PMs had high ventricular pacing rates at the last interrogation (69 ± 36.0%) and often suffered atrioventricular block (39.2%). Six (25%) of the 24 active ICDs presented shocks near the time of death. CONCLUSION: Many CIED patients died in hospital; nonetheless, in practice, CIED deactivation near death is rarely performed and might be less feasible in subjects with PMs. However, there is still a need to consider deactivation, especially in individuals with ICDs, as one fourth of them received at least one shock within 24 h prior to death.

Individual programming of current multiprogrammable pacemakers : Still unsatisfactory?

BACKGROUND: Pacemaker (PM) technology has developed tremendously in recent decades. We evaluated the extent of individual programming in current PMs. METHODS: Over a 7-month period in 2016, all deceased persons taken to the Rostock crematorium were prospectively screened for cardiac implantable electronic devices (CIEDs) and these were interrogated in situ. Programming of patient data, leads, and study parameters including mode, lower rate, upper tracking or sensor rate (UTSR), ventricular refractory time, sleeping function, hysteresis, and PM-mediated tachycardia intervention were analyzed and compared with delivery settings. Alterations in atrial/ventricular capture management and atrial/ventricular sensing assurance as well as changes in sensitivity and lead output were evaluated. RESULTS: We examined 2297 subjects, of whom 154 (6.7%) had CIEDs, with 125 (81.2%) being PMs. Finally, 72 (57.6%) PMs were eligible for analysis with an operation time of 31.0 ± 27.0 months. We excluded 28 (18.2%) implantable cardioverter defibrillators (ICDs), 51 (41%) PMs presenting elective replacement indicator (ERI), two (1.6%) PMs with programming to insufficient function prior to death, and the left ventricle parameter of one (1.4%) cardiac resynchronization therapy pacemaker (CRT-P); further one CIED (0.6%) was not contactable. PMs offered in mean 75.2% of study parameters thereof 88.0% were to adjust manually, whereof 49.3% stayed unchanged to delivery mode. Lead output, UTSR, lower rate, and mode were the most frequently changed parameters (>85.7%, 65.3%, 54.2%, and 52.8%, respectively) compared with unmodified ventricular refractory time and hysteresis (91.7% and. 85.4%, respectively); 2.8% of PMs had out-of-the-box settings. The most frequent personalized data were last (88.9%) and first name (73.6%), while atrial and ventricular serial lead numbers were rarely entered (18.2% and 23.4%, respectively). CONCLUSION: The programming possibilities of PMs have advanced greatly. Nonetheless, improvements in individual PM programming are still needed as demonstrated by the findings in this study, e.g., PMs with manufacturer settings and lack of individual data.

[Premature wear of total knee arthroplasty in sports shown in a golfer]. / Vorzeitiger Verschleiß von Knieendoprothesen im Sport am Beispiel eines Golfers.

Sport with an endoprosthesis is controversially discussed, whereas golf with a knee endoprosthesis is usually allowed. This case shows that playing golf can lead to severe wear of the prosthesis. The wear pattern of the components of the prosthesis suggests increased rotational loads. A change to a constrained prosthesis was made because of metal-to-metal contact. It is important to inform the patient before surgery about sports with endoprosthesis. Athletic loads are not part of prosthesis testing according to ISO.

Outcome of Surgical and Conservative Treatment of Patients with Shoulder Impingement Syndrome - a Prospective Comparative Clinical Study.

PURPOSE OF THE STUDY Subacromial impingement is one of the most common reasons for shoulder pain. The surgical management of this condition has recently become the focus of criticism because of the rising number of surgical procedures and the lack of superiority of surgical over conservative treatment. In this prospective comparative study, we compared standardised conservative care with surgical treatment and placed special emphasis on the patients' ability to work. MATERIAL AND METHODS A total of 106 patients (25 women, 81 men; mean age: 45.4 12.3 years) were included in this prospective comparative clinical study. Patients in the non-operative arm (n = 42) received standardised physiotherapy. Patients in the surgical arm (n = 38) underwent arthroscopic subacromial decompression. All patients were followed up at 3, 6 and 12 months. Shoulder function (Constant score), pain (Numerical Rating Scale), and the duration of inability to work were assessed. RESULTS Shoulder function and pain improved significantly with both kinds of treatment. At no time of follow up we detected significant differences between the two treatment options. An analysis of the patients' ability to work showed that conservative treatment was superior to surgical treatment at 3-month follow-up (0.3 versus 5.0 weeks; p < 0.001) and between 4 and 6-month after intervention (0.2 versus 1.6 weeks; p = 0.032). DISCUSSION In the study presented here, significant improvements in function (Constant score) and pain (NRS) were achieved in both the non-operative and the surgical arm. There were no significant differences between the two groups at any time point. These results are similar to those reported by other authors in recent studies. Unlike other research work, however, our study demonstrated a major difference in the development and duration of inability to work. CONCLUSIONS Conservative and surgical treatment of subacromial impingement syndrome led to similar outcomes for shoulder pain and function at 3, 6 and 12 months after intervention. However, patients who were managed conservatively returned to work significantly earlier than patients who underwent surgery. Key words: subacromial impingement, shoulder, constant score, pain, ability to work.

[What do orthopedic and trauma surgeons expect from radiologists when interpreting imaging of the elbow?] / Was erwarten Orthopäden und Unfallchirurgen vom Radiologen bei der Beurteilung der Bildgebung des Ellenbogens?

CLINICAL ISSUE: The elbow is a complex joint with a multitude of acute and chronic pathologies. In addition to the clinical examination, radiological diagnostics play a decisive role in the further therapeutic management. DIAGNOSTIC WORK-UP/PERFORMANCE: While acute traumatic injuries often present with obvious structural changes and the need for rapid treatment decisions, chronic processes can present with less evident alterations. Especially in these cases there is a need for clear communication between the treating physician and the radiologist with respect to managing optimal imaging as the basis for a certain diagnosis and therefore optimal treatment. Basic prerequisites on both sides are detailed knowledge of all elbow pathologies, classifications and the spectrum of radiological diagnostic imaging. ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS: From the point of view of orthopedic surgeons the radiologist is responsible for the correct performance and interpretation of the necessary imaging procedures. The aim of this article is to give an overview of important aspects in the imaging of typical orthopedic/traumatic pathologies.

[Osteotomies around the knee for ligament insufficiency]. / Kniegelenknahe Osteotomien bei Bandinsuffizienzen.

BACKGROUND: The osseous geometry of the lower limb has a significant impact on knee instability after ligament injuries, and osseous malalignment has been shown to be a significant risk factor for the failure of ligament reconstruction procedures. Therefore, osteotomies around the knee have gained importance as a combined or isolated treatment option in the ligament deficient and malaligned knee. In addition to unloading of an arthritic knee compartment, osteotomies are also performed to protect a reconstructed ligament and to stabilize the joint without ligament surgery. PROCEDURE: In addition to the correction of varus or valgus malalignment, correction of sagittal imbalance by modifying the tibial slope is an emerging concept. Even small modifications of the tibial slope (≤5°) have been shown to change the anterior-posterior translation in a clinically significant manner. Especially in the case of chronic posterior or posterolateral instability, a valgus-producing and slope-increasing high tibial osteotomy is usually the first treatment option, and ligament surgery is only performed optionally. Isolated modification of the tibial slope is performed infrequently, however, a slope-decreasing osteotomy should be considered in patients with multiple failed ACL reconstructions and a tibial slope of >12°.

Single-catheter approach to pulmonary vein reisolation in selected patients : Data from a prospective registry.

BACKGROUND: In addition to different types of single-tip ablation catheters for pulmonary vein (PV) reisolation, a newly developed circular mapping and ablation catheter (nMARQ®) has been available since 2013 and is currently used only in initial PV isolation procedures. In this prospective registry we present feasibility and efficacy data for PV reisolation procedures with a single-catheter approach (nMARQ®) compared with a standard approach using a single-tip ablation catheter and a circular mapping catheter. METHODS: We included 35 carefully selected patients in this prospective registry and assigned them in a 2:1 ratio to undergo either PV reisolation with a single-tip ablation catheter together with a steerable circular mapping catheter (group 1) or with the nMARQ®catheter only (group 2). The recurrence rate was calculated for atrial tachyarrhythmias with a duration of > 30 s during a mean follow-up of 12.7 months. RESULTS: Reisolation of all PVs was achieved in all patients of both groups. In group 2, all gaps could be correctly identified with the nMARQ® catheter. PV isolation was clearly visible on the nMARQ® catheter in all targeted veins. With the nMARQ® catheter the ablation time decreased significantly (6.3 ± 3.0 vs. 18.6 ± 13.9 min, p < 0.05). The recurrence rate of atrial fibrillation did not differ significantly between the two groups (37.5 vs. 45.5 %, p = 0.66). CONCLUSION: In selected patients, a complete PV reisolation procedure is feasible with a singular circular mapping and ablation catheter. The 12-months success rate is comparable to a classic approach with a combination of a single-tip ablation catheter and a circular mapping catheter.

Stem cells and bFGF in tendon healing: Effects of lentiviral gene transfer and long-term follow-up in a rat Achilles tendon defect model.

BACKGROUND: The influence of stem cells and lentiviral expression of basic fibroblastic growth factor (bFGF) on tendon healing and remodelling was investigated in an in-vivo long-term (12 weeks) rat Achilles tendon defect model. METHODS: In sixty male Lewis rats, complete tendon defects (2.4 mm) were created and either left untreated (PBS) or treated by injection of stem cells lentivirally expressing the enhanced green fluorescence marker gene eGFP (MSC-LV-eGFP) or basic fibroblast growth factor bFGF (MSC-LV-bFGF). Tendons were harvested after 12 weeks and underwent biomechanical and (immuno)-histological analysis. RESULTS: After 12 weeks the mean ultimate load to failure ratio (treated side to contralateral side) in biomechanical testing reached 97 % in the bFGF-group, 103 % in the eGFP-group and 112 % in the PBS-group. Also in the stiffness testing both MSC groups did not reach the results of the PBS group. Histologically, the MSC groups did not show better results than the control group. There were clusters of ossifications found in all groups. In immunohistology, only the staining collagen-type-I was strongly increased in both MSC groups in comparison to PBS control group. However, there were no significant differences in the (immuno)-histological results between both stem cell groups. CONCLUSION: The biomechanical and (immuno)-histological results did not show positive effects of the MSC groups on tendon remodelling in a long-term follow-up. Interestingly, in later stages stem cells had hardly any effects on biomechanical results. This study inspires a critical and reflected use of stem cells in tendon healing.

[Muscle, tendon and joint injections : What is the evidence?]. / Injektionen an Muskeln, Sehnen und Gelenken : Was ist die Evidenz?

Injections at tendon insertions, in muscles and in joints are an important instrument in the conservative treatment of musculoskeletal diseases, for acute injuries as well as for chronic degenerative diseases. Local anesthetic agents and glucocorticoids are well-established medications; however, severe side effects, such as chondrolysis have sometimes been reported, particularly for local anesthetic agents. In addition platelet rich plasma (PRP) and hyaluronic acid are also widely used; however, the clinical effectiveness has not always been proven. This article gives an overview on the most commonly used medications for injections and the mechanisms of action. The indications for treatment and the evidence for the clinical adminstration of muscle, tendon and joint injections are described based on the currently available literature.

[Biomaterials in orthopedics]. / Biomaterialien in der Orthopädie.

Biomaterials are artificial or natural materials, which are used in living organisms for a wide variety of reasons. Currently, there are biomaterials available for practically all types of tissue and can fulfill temporary and permanent functions. Ideally, materials used for temporary roles should be completely resorbed after the fulfilling the function and those with a permanent role should remain stable within the body. Many of the currently available biomaterials do not possess these optimal features. Those with temporary roles often remain unchanged within the organism or only induce an incomplete regeneration and those with permanent roles suffer biological alterations which reduce the function. Despite the enormous number of biomaterials, it must always be considered whether the therapeutic target can be achieved without using an implant.

[Conservative treatment of chronic tendinopathies]. / Konservative Therapie der chronischen Enthesiopathien.

The majority of insertional and noninsertional tendinopathy cases are associated with repetitive or overuse injuries. Certain tendons are particularly vulnerable to degenerative pathology; these include the Achilles and patella tendon, the rotator cuff, and forearm extensors/flexors. Disorders of these tendons are often chronic and can be difficult to manage successfully in the long term. Eccentric exercise has the strongest evidence of therapeutic efficacy. Extracorporeal shock wave treatment, sclerosing agents as well as nitric oxide patches show promising early results but require long-term studies. Corticosteroid and nonsteroidal antiinflammatory medications have not been shown to be effective except for temporary pain relief for rotator cuff tendinopathy. Platelet-rich plasma injections show encouraging short-term results.

[Conservative therapy of osteoarthritis]. / Konservative Therapie der Gonarthrose.

Osteoarthritis of the knee is a degenerative joint disease with progressive degradation of articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking and joint effusion depending on the stage of the disease. In an effort to delay major surgery, patients with knee osteoarthritis are offered a variety of nonsurgical modalities, such as weight loss, exercise, physiotherapy, bracing, orthoses, nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular viscosupplementation or corticosteroid injection. In general, the goals of these therapeutic options are to decrease pain and improve function. Some of these modalities may also have a disease-modifying effect by altering the mechanical environment of the knee. Chondroprotective substances, such as lucosamine, chondroitin sulphate and hyaluronic acid are safe and provide short-term symptomatic relief while the therapeutic effects remain uncertain.

[Musculoskeletal modeling of the patellofemoral joint. Dynamic analysis of patellar tracking]. / Muskuloskelettale Modellierung des patellofemoralen Gelenks. Dynamische Analyse der patellaren Führung.

Numerical simulations contribute to the understanding of patellofemoral diseases. Whereas cadaveric studies are limited with respect to reproducibility of results, the impact of different operative approaches can be systematically evaluated based on mathematical models. The objective of this study was to introduce a musculoskeletal model which is capable of describing the dynamic interactions within the patellofemoral joint. It contains major bony and soft tissue structures of the right leg including the medial patellofemoral ligament (MPFL). Two operative approaches were considered based on the model to illustrate the effect on patellofemoral biomechanics during active knee flexion: On the one hand the effect of femoral insertion during MPFL reconstruction on medial soft tissue tension, and on the other hand the difference in patella kinematics before and after total knee arthroplasty. Finally, the potential of musculoskeletal models is discussed.

[Calcific tendinitis of the shoulder]. / Die Kalkschulter - Tendinosis calcarea.

Calcific tendinitis of the shoulder is a process involving crystal calcium deposition in the rotator cuff tendons, which mainly affects patients between 30 and 50 years of age. The etiology is still a matter of dispute. The diagnosis is made by history and physical examination with specific attention to radiologic and sonographic evidence of calcific deposits. Patients usually describe specific radiation of the pain to the lateral proximal forearm, with tenderness even at rest and during the night. Nonoperative management including rest, nonsteroidal anti-inflammatory drugs, subacromial corticosteroid injections, and shock wave therapy is still the treatment of choice. Nonoperative treatment is successful in up to 90% of patients. When nonsurgical measures fail, surgical removal of the calcific deposit may be indicated. Arthroscopic treatment provides excellent results in more than 90% of patients. The recovery process is very time consuming and may take up to several months in some cases.

[Biphosphonate-induced femoral stress fractures : A new problem and knowledge so far - case report]. / Bisphosphonatinduzierte Stressfrakturen am Femur : Ein neues Problem und bisherige Erkenntnisse - Fallbericht.

During the last several years the treatment of osteoporosis with bisphosphonates has become accepted as a safe and effective procedure. However, recently there have been increasing numbers of reports of rare complications in the literature. Particularly the occurrence of atypical fractures of the femur has become a focus of interest but the problem is insufficiently known and only rarely addressed in the scientific discussion. The case illustrated here and a survey of the important facts in the recent literature highlight essential aspects of long-term bisphosphonate therapy.

Does the anterolateral ligament protect the anterior cruciate ligament in the most common injury mechanisms? A human knee model study.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction still has a risk of re-rupture and persisting rotational instability. Thus, extra-articular structures such as the anterolateral ligament (ALL) are increasingly treated. The ALL however prevents the internal rotation of the tibia and it must be doubted that the ALL protects the ACL in other common injury mechanisms which primarily include tibial external rotation. In this study we aimed to evaluate which extra-articular structures support the ACL in excessive tibial internal and external rotation using a knee finite element (FE) model. METHODS: Internal and external rotations of the tibia were applied to an FE model with anatomical ACL, posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL) and intact medial and lateral meniscus. Three additional anatomic structures (anterolateral ligament, popliteal tendon and posterior oblique ligament) were added to the FE model separately and then all together. The force histories within all structures were measured and determined for each case. RESULTS: The ACL was the most loaded ligament both in tibial internal and external rotation. The ALL was the main stabilizer of the tibial internal rotation (46%) and prevented the tibial external rotation by only 3%. High forces were only observed in the LCL with tibial external rotation. The ALL reduced the load on the ACL in tibial internal rotation by 21%, in tibial external rotation only by 2%. The POL reduced the load on the ACL by 8%, the PLT by 6% in tibial internal rotation. In tibial external rotation the POL and PLT did not reduce the load on the ACL by more than 1%. CONCLUSION: The ALL protects the ACL in injury mechanisms with tibial internal rotation but not in mechanisms with tibial external rotation. In injury mechanisms with tibial external rotation other structures that support the ACL need to be considered.

Results of a tri-national online survey on the current status of sports injury prevention among members of the German-Speaking Orthopaedic Sports Medicine Society (GOTS).

OBJECTIVES: To assess the current opinions and state of knowledge in primary sports injury prevention among members of the German-Speaking Society for Orthopaedic and Traumatologic Sports Medicine (GOTS). METHODS: On 21 August 2019, a web-based questionnaire was sent to the members of the tri-national society GOTS (Austria, Germany and Switzerland). The survey was online until 21 November 2019 and included twenty-two questions, which were divided into five sections: 1) general importance of prevention (n = 4), 2) specifications of the study population (n = 3), 3) implementation of prevention (n = 8), 4) improvement opportunities in prevention (n = 4) and 5) future research areas (n = 3). RESULTS: A total of 272 participants completed the survey, representing a total survey participation of 17.7 % of all members. The study population consisted of orthopaedic surgeons (55 % with surgical and 21 % with non-operative orientation), medical students (10 %), physical therapists (8 %) and sports scientists (4 %). Ninety-four percent of all participants stated that they considered the importance of sports injury prevention to be "very high" (68 %) or "high" (26 %). However, almost 70 % of all participants stated that they spend less than one hour per week on injury prevention work. The term "prevention" was clearly defined and practicable for only 40 %, understandable but difficult to implement for 51 %, and unclear and difficult to implement for 9 % of the participants. Seventy-two percent of respondents were aware of existing prevention programs such as "Stop-X" or "FIFA 11 +", whereas 28 % of participants were uninformed regarding these programs. CONCLUSIONS: A strong divergence was identified between participants' perception of the importance of sports injury prevention and the existing implementation of preventive measures. Future funding of prevention programs, expansion of research strategies for injury prevention and better financial reimbursement are of utmost importance.

Platelet-rich plasma (PRP) as therapy for cartilage, tendon and muscle damage - German working group position statement.

PURPOSE: Platelet rich plasma (PRP) is widely used in orthopaedics, but is still heavily debated. Therefore, a survey among the German "Working Group for Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology was conducted to achieve a consensus about the current therapeutical potential of PRP. METHODS: A first survey (n = 65 experts, all orthopaedic/trauma surgeons) was conducted (n = 13 questions). Following, a second round (n = 40 experts) was conducted with 31 questions to achieve consensus in 5 categories: three most common indications, PRP application, future research areas. RESULTS: Therapeutic PRP application was regarded as useful (89%), possibly even more important in the future (90%). Most common indications were tendon pathologies (77%), osteoarthritis (OA) (68%), muscle injuries (57%) and cartilage damage (51%). Consensus was reached in 16/31 statements. The application of PRP for early knee OA (Kellgren-Lawrence grade II) was regarded as potentially useful, as well as for acute and chronic tendinopathies. For chronic lesions (cartilage, tendons), multiple injections (2-4) were seen preferable to singular injections. However, no sufficient data exists on the time interval between the injections. Standardization of PRP preparation, application, frequency, as well as determining the range of indication is strongly recommended. CONCLUSIONS: There is a need of further standardization of the PRP preparation methods, indication and application protocols for knee OA and other indications, which must be further evaluated in basic science studies and randomized controlled clinical trials. LEVEL OF EVIDENCE: Consensus of expert opinion, Level V.

Dose-dependent osteoinductive effects of bFGF in rabbits.

Growth factors lead to the induction of tissue regeneration in bone healing when coated on biomaterials. Basic fibroblast growth factor (bFGF) combines osteoinduction and neoangiogenesis. This study evaluated bFGF-coated hydroxylapatite implants in two experimental groups with 10 or 100 microg (n = 5 per group) compared with uncoated control implants in the rabbit patellar groove model. We observed an unexpected ineffectiveness compared to the control groups with no significant difference of bone growth after 35 days. However, all samples from the 100 microg experiment (control and coated implant) showed significantly stronger 19-25 day label than both 10 microg groups (control and coated implant). Earlier bone labels are stronger in the 10 microg group with equal observation of similarity between experiment and control site and may indicate a possible inhibitory effect of the higher dosing or osteoclast induction. This result indicates a possible systemic effect of the transient growth factor coating.