Ultrasound of horizontal instability of the acromioclavicular joint : A simple and reliable test based on a cadaveric study.

BACKGROUND: Horizontal instability influences the clinical outcome after acromioclavicular joint (ACJ) injuries and in joint degeneration. A standardized, dynamic examination of the horizontal instability has not been described before. This current study presents a sonographic method to analyze the dynamics between the clavicle and acromion in the horizontal plane. METHODS: The horizontal joint play, the ACJ space and the offset between clavicle and acromion were sonographically assessed by a 45° ventrally angulated longitudinal section. A total of four investigators with different experience in the field of musculoskeletal ultrasound examining 20 ACJs in 10 human cadavers. Measurements in the absence of any pressure and under standardized anterior and posterior pressure onto the clavicle were carried out in different ligament status intact acromioclavicular (AC) and coracoclavicular (CC) ligaments as well as in a Rockwood (RW) II and III model. A two-sided t­test was used to examine the differences between joint positions and ligament status. RESULTS: The horizontal joint play was 1.3 ± 0.9 mm with intact ligaments, 1.4 ± 1.2 mm by transecting the AC ligaments and 1.9 ± 1.3 mm after additionally transecting the CC ligament. The joint space was 3.3 ± 1.1 mm with intact ligaments, 4.1 ± 1.8 mm in an iatrogenic RW 2 injury, and 5.3 ± 3.3 mm in an iatrogenic RW 3 injury. Manipulating the clavicle by applying anterior or posterior pressure did not change the difference within one injury pattern. Interobserver reliability was 83.9%. CONCLUSION: Apart from evaluating the ligaments and the joint capsule, measurement of the dynamic horizontal instability is possible in a human cadaver model. The ultrasound-based measurement of horizontal instability dynamics avoids radiation exposure, is readily available and cost-efficient.

Preoperative MRI is helpful but not sufficient to detect associated lesions in patients with chronic ankle instability.

PURPOSE: The aim of this study was to determine the reliability and validity of preoperative magnetic resonance imaging (MRI) scans for the detection of additional pathologies in patients with chronic ankle instability (CAI) compared to arthroscopic findings. METHODS: Preoperative MRI images of 30 patients were evaluated regarding articular and periarticular comorbidities and compared to intraoperative findings. The reliability of MRI was determined by calculating specificity, sensitivity, as well as positive and negative predictive values. The accuracy of the classification of cartilage lesions by Outerbridge and Berndt and Harty rating scales was determined by calculating the area under the receiver operating curve (AUC). RESULTS: In total, 72 additional pathologies were found arthroscopically compared to 73 lesions gathered from MRI images. Sensitivity ranged from 89% for peroneal tendinopathy to 28% for additional ligamentous lesions. Specificity ranged from 100% for anterolateral impingement, loose bodies and peroneal tendinopathy to 38% for additional ligamentous lesions. For cartilage lesions, sensitivity was at 91% and specificity was at 55% for the Outerbridge grading scale. For the Berndt and Harty classification system, sensitivity was at 91% and specificity was at 28%. Correlation of additional pathologies ranged from weak (r s = 0.48; p = 0.02) to moderate results (r s = 0.67; p < 0.001). CONCLUSION: CAI is associated with a high incidence of additional pathologies. In some cases, MRI delivers insufficient results, which may lead to misinterpretation of present comorbidities. MRI is a helpful tool for preoperative evaluation, but arthroscopy remains gold standard in the diagnosis of associated lesions in patients with CAI. LEVEL OF EVIDENCE: III.

Climbing Has a Positive Impact on Low Back Pain: A Prospective Randomized Controlled Trial.

OBJECTIVE: Comparison of climbing versus no treatment to treat chronic low back pain. DESIGN: Prospective randomized controlled trial. SETTING: Tertiary. PARTICIPANTS: A total of 30 patients with chronic low back pain were recruited and randomly assigned to 2 different groups: climbing and control. The inclusion criteria were defined as chronic low back pain, age between 18 and 45 years, body mass index lower than 25, and no climbing experience. INTERVENTIONS: Patients in the climbing group were instructed to climb 5 different climbing routes. A climbing activity of 10 sessions in 8 weeks, at least once a week with a minimum duration of 1 hour, was mandatory. MAIN OUTCOME MEASURES: The participants were examined before (T0) and after therapy (8 weeks, T8) and after another 6 weeks (T14). The outcome was evaluated using Oswestry Disability Index, Visual Analog Scale (VAS), Likert scale, and magnetic resonance imaging (MRI). Radiologists evaluating MRI were blinded. The study was performed as a single-center study. RESULTS: Evaluating the Oswestry Disability Index, a significant difference in the time course between the 2 groups was detected (P = 0.022). Significant improvements comparing climbing and control group were also found when assessing VAS in a minimal finger-floor-distance position (P = 0.048). Patients in the climbing group showed a reduction in size of disc protrusion. CONCLUSIONS: Climbing may be an effective and low-cost therapy option for people with chronic low back pain. CLINICAL RELEVANCE: Low back pain is a very common disease but still a challenge to treat. Therapy strategies vary from conservative ones, pharmacological treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and weak opioids, to invasive treatment with acupuncture, injections, and operative reconstruction. Some can be costly and not without risks. For instance, many people who use NSAIDs are at risk of common side effects such as gastrointestinal complications (irritation, ulcers, and bleeding) that may lead to hospitalization. Climbing could offer reduction of pain and better performance in daily life, because it offers a closed chain muscle training that has the potential to improve posture, perception of the trunk midline, and muscle control. Climbing may also lead to a better adherence to continuing treatment than traditional physical therapy and exercise due to a more exciting aspect of the sports activity.

Comparison of plantar-pressure distribution and clinical impact of anatomically shaped sandals, off-the-shelf sandals and normal walking shoes in patients with central metatarsalgia.

PURPOSE: Metatarsalgia is one of the most frequent pathological conditions of the foot and ankle. Numerous studies exist on plantar-pressure characteristics in various types of shoes. However, to the best of our knowledge, plantar-pressure distribution and clinical effects in sandals has not as yet been the the focus of any study. METHODS: Twenty-two patients (42 feet) with central metatarsalgia were assessed. Time and distance until symptom occurrence in terms of metatarsalgia were evaluated for normal walking shoes (WS), standard sandals (SS) and anatomically shaped, custom-made sandals with a metatarsal pad (AS). Pain intensity was measured with the visual analogue (VAS), and clinical assessment was performed with the American Orthopaedic Foot and Ankle Society (AOFAS) score for the respective shoes. Additionally, plantar-pressure distribution was assessed with the emed-at platform (Novel GmbH) and the F-scan insole system (Tekscan Inc.), respectively. RESULTS: The average walking distance until symptoms occurred was 1,894 m [standard deviation (SD) 1,196 m) for WS, 1,812 m (SD 1,079 m) for SS and 3,407 m (SD 1,817 m) for AS (p < 0.01). Mean duration until occurrence of symptoms was 22.3 min (SD 14.9 min) for the WS, 21.8 min (SD 13.4 min) for the SS and 42.0 min (SD 23.0 min) for the AS (p < 0.01). Plantar-pressure parameters were significantly reduced in the forefoot region for the AS compared with the other walking devices. CONCLUSIONS: The results of this study reveal that a modified standard sandal can significantly influence the onset of metatarsalgia, as increased walking time and distance in these patients was observed.

Intra-articular versus periarticular acromioclavicular joint injection: a multicenter, prospective, randomized, controlled trial.

PURPOSE: The purpose of this randomized study was to compare the clinical efficacy of intra-articular versus periarticular acromioclavicular joint injections. METHODS: In this multicenter, prospective, randomized, controlled trial, 101 patients (106 shoulders) with symptomatic acromioclavicular joints were treated with an injection and were randomly assigned to either the intra-articular group or the periarticular group. To ensure accurate needle placement either intra-articularly or in a periarticular manner, the needle was placed under ultrasound guidance. Baseline values including the Constant-Murley score, pain assessment with a visual analog scale for pain under local pressure and pain at night, and the crossover arm test were investigated in 7 different centers immediately before treatment. Follow-up examinations were scheduled after 1 hour, 1 week, and 3 weeks. RESULTS: All patients completed the study. Overall, a highly significant clinical improvement in all tested variables and in both groups was observed over time (P < .0001) beginning with 1 hour after treatment and lasting for the entire follow-up period of 3 weeks. The difference between the 2 groups was not significant except regarding the crossover arm test (P < .016). CONCLUSIONS: With both injection techniques, a highly significant clinical advantage for the patient can be achieved. The difference between the 2 treatments was not significant except for more pain reduction according to the crossover arm test after intra-articular injection at 3 weeks' follow-up. LEVEL OF EVIDENCE: Level II, multicenter, randomized, prospective, controlled trial.

Contamination of surfaces for osseointegration of cementless total hip implants by small aluminium oxide particles: analysis of established implants by use of a new technique.

BACKGROUND: The failure of total hip replacements because of wear, particle-induced osteolysis, and aseptic loosening has focussed interest on factors potentially affecting the rate of wear. In this context the effect of particle release from the bone-implant interface of cementless implants is poorly understood. The surface structure for bony ongrowth of many cementless implants is created by grit-blasting. Remnants from this process (Al2O3 particles) on these surfaces have been reported; these remnants have the potential to cause third-body wear. METHODS: We report a novel technique for isolation and quantification of alumina particle contamination. Stems from different manufacturers were electrochemically activated and etched to isolate the alumina residues. After filtration the particles were characterised by scanning electron microscopy and energy-dispersive X-ray analysis. RESULTS: Many Al2O3 particles were found on all the implants tested. A mean of 426,814 particles per mm(2) was measured. Particle size distribution ranged from 0.125 to 66.304 µm with a peak in the range 0.25-1 µm. CONCLUSIONS: Our main finding was a large amount of small Al2O3 particles on all blasted surfaces. On the basis of our results these alumina particle remnants cannot be excluded as a factor causing increased third-body wear.

Treatment of peroneal tendon dislocation and coexisting medial and lateral ligamentous laxity in the ankle joint.

PURPOSE: Acute dislocation of the peroneal tendon is caused by massive combined flexion-torsion trauma supported by preexisting ligamentous laxity of the ankle joint. This study aimed to investigate the clinical outcome of combined treatment of peroneal tendon dislocation and lateral and medial ligamentous laxity. METHODS: Between 2005 and 2007, forty-two patients with peroneal tendon dislocation and coexisting ligamentous laxity were treated. The superior extensor retinaculum was reconstructed using anchor technique and periosteal flap repair, whereas the preexisting ligamentous laxity with regard to the extensor inferior retinaculum was addressed using anchor reconstruction. All patients underwent arthroscopy prior to surgery. Thirty-eight of a total of 42 patients (aged 17-31) completed the 24-month follow-up. Clinical and arthroscopic examination was accomplished consistently by always the same two surgeons. Postoperative follow-up comprised clinical evaluation after 3, 6, 12 and 24 months. RESULTS: Clinical results showed a significant (P<0.0001) increase in the AOFAS-Hindfoot Score as an often used but not validated outcome measure, as well as a significant decrease in the Visual Analogue Scale and in the internal and external rotation, after 3 months. The clinical outcome was confirmed at the 6-, 12- and 24-months measuring points. No dislocation of the peroneal tendon recurred within the 24-month follow-up. Subjective patient satisfaction was stated as high. CONCLUSIONS: Combined treatment of peroneal tendon dislocation and coexisting lateral and medial ligamentous laxity in the ankle joint following arthroscopy results in good clinical outcome and high patient satisfaction. LEVEL OF EVIDENCE: Case series, Level IV.

Extracorporeal shockwave therapy in calcifying tendinitis of the shoulder.

PURPOSE: Strategies for extracorporeal shockwave therapy in calcifying tendinitis of the rotator cuff vary concerning quantity of sessions and doses. The purpose of this prospective pilot study was to determine the difference between the outcome of a single high-dosage extracorporeal shockwave therapy and two sessions of low-dosage extracorporeal shockwave therapy. METHODS: This study compared a single high-level middle-energetic extracorporeal shockwave therapy (0.3 mJ/mm(2)) with a low-level middle-energetic extracorporeal shockwave therapy applied twice in a weekly interval (0.2 mJ/mm(2)). Thirty patients that suffered from calcifying tendinitis for at least 6 months received navigated, fluoroscopy-guided extracorporeal shockwave therapy. The gain of Constant Murley Score, Visual Analogue Scale during state of rest and weight-bearing situations ("stress") and radiographic progress was documented 6 and 12 weeks after therapy. RESULTS: In both groups, a significant reduction in pain during stress and improvement of function was observed. In contrast, no significant reduction in pain during rest was observed. No significant difference between both groups concerning reduction in the calcific deposit after 6 weeks was detected. Group B showed minor advantages in radiographical improvement after 12 weeks. In 36% of the patients, the calcific deposit completely dissoluted after 12 weeks. CONCLUSIONS: This pilot study indicates that a single high-level extracorporeal shockwave therapy may be as effective as two applications of a lower-dosed extracorporeal shockwave therapy for calcifying tendinitis. An effective single-session strategy could reduce treatment time, material costs and healthcare expenses and ionizing radiation in case of fluoroscopy guidance.

Low-grade chondrosarcoma of bone: experiences from the Vienna Bone and Soft Tissue Tumour Registry.

In a retrospective single-centre study, 70 low-grade chondrosarcoma (LCS) (31 female/39 male patients with a mean age of 40 years) were reviewed to evaluate surgical management. The mean overall follow-up was 81 months (median: 73 months, range: 6-317 months). Seventeen lesions (24.3%) in the trunk and 53 (75.7%) in the extremities were treated by curettage (48.6%) or resection (51.5%). Local recurrence occurred in eight patients (11.4%) 18 months postoperatively (median: 18 months, range: 0-41 months). Recurrence-free survival was significantly better for patients with extremity lesions compared to truncal lesions, but was not affected by resection margin. The anatomical site "trunk" and an "intralesional" resection margin had a significant independent prognostic influence in multivariate analysis. Curettage with local adjuvants is a viable treatment option for most extremity LCS. In truncal LCS wide resection is recommended despite a potentially higher complication rate.

The anxiolytic effect of pregabalin in outpatients undergoing minor orthopaedic surgery.

Preoperative anxiety can increase postoperative pain and is therefore important to avoid. Different approaches have already been tested for preoperative anxiolysis. Gabapentinoids might be a useful alternative to benzodiazepines. Pregabalin is used for treating generalized anxiety disorders and shows a favourable pharmacokinetic profile after oral administration; however, its anxiolytic effect preoperatively in healthy outpatients is still unclear. In this randomised, double-blind, placebo-controlled trial the anxiolytic effect of pregabalin in 40 outpatients undergoing standardised general anaesthesia and postoperative pain therapy for minor orthopaedic surgery was analysed. Patients received preoperatively either 300 mg pregabalin or placebo orally. The primary outcome was anxiety before anaesthesia induction, the secondary outcome the postoperative pain, both assessed using a visual analogue scale from 0 to 100. Without any side effects pregabalin reduced preoperative anxiety compared with the control group (23 ± 10 vs. 38 ± 17; p = 0.003). Pain scores did not differ between groups; however, need of piritramide in the postanaesthesia care unit was reduced to half by pregabalin compared with the control group. A single preoperative dose of 300 mg pregabalin reduces anxiety in patients undergoing minor orthopaedic surgery without any side effects like dizziness or persisting sedation resulting in a prolonged stay in the postanaesthesia care unit.

Ultrasound guidance improves the accuracy of the acromioclavicular joint infiltration: a prospective randomized study.

Degeneration of the acromioclavicular joint (AC) often causes impaired shoulder function and pain. Its infiltration results in reportedly beneficial short-term effects. Misplacement of infiltrations is observed in high numbers. A previous study showed high accuracy of infiltrations of one surgeon comparing conventional palpation technique to ultrasound guidance. This study evaluates if ultrasound-guided AC joint infiltration is feasible for therapists of different levels of experience and if the accuracy can be increased. One hundred and twenty AC joints of 60 cadavers were enrolled into a prospective, randomized observer-blinded study. Six therapists of three different levels of experience infiltrated 20 AC joints each. Half of them were infiltrated after palpation of the joint space, half of them were ultrasound-guided infiltrated. Controls were performed pre- and post-infiltration by an independent radiologist. In total, accurate infiltration was observed in 70%. In 25%, misplacement of the infiltration was recorded in the palpation-, in 2% in the ultrasound- and in 3% in both groups. The difference between the two groups was significant (P = 0.009). Ultrasound-guided infiltration to the AC joint is significantly more accurate than conventional palpation technique. This method is simple, efficient and can be applied by therapists of all levels of experience.

Combined medial and lateral anatomic ligament reconstruction for chronic rotational instability of the ankle.

BACKGROUND: This study aimed to extend knowledge on the arthroscopic evaluation of the unstable ankle joint and the outcome of ligament reconstruction on rotational instability. In contrast to previous studies, we investigated the combined repair of lateral and medial ligaments. METHODS: Ninety-six patients underwent medial and lateral ligament reconstruction between 2006 and 2008, 81 of whom, with a mean age of 31.9 (range, 14 to 44) years, completed the 12-month followup and were therefore included in this study (Table 1). Clinical, radiographic, and concomitant arthroscopic examination was performed prior to the ligament stabilization. Postoperative followup included clinical and radiographic evaluation after 3, 6, and 12 months. RESULTS: Arthroscopy showed a lesion of the anterior fibulotalar ligament (AFTL), calcaneofibular ligament (CFL), and tibiocalcanear ligament (TCL) (Deep part of deltoid ligament complex) in 67 patients. An avulsion of the proximal insertion point of the ATTL was additionally found in 14 cases. Clinical results 3 months after surgery showed a significant increase in the AOFAS-Hindfoot Score as well as a significant decrease of the Visual Analogue-Scale for pain (VAS) (p < 0.0001). This outcome persisted at the 12-month examination. CONCLUSION: Rotational instability of the ankle joint in most cases has an injury of the lateral ligaments and a component of the deltoid, the TCL, but rarely with a combined lesion of the TCL and the anterior tibiotalar ligament (ATTL) (Superficial part of deltoid ligament complex). The combined lateral and medial ligament reconstruction with an anchor technique had a good clinical outcome with high patient satisfaction with few complications.

Extracorporeal shock wave therapy in the treatment of calcific tendinitis of the rotator cuff.

BACKGROUND: Low-energy extracorporeal shock wave therapy is an alternative treatment, with limited evidence for effectiveness, for calcific tendinitis of the rotator cuff. HYPOTHESIS: Objective localization of the calcium deposit by 3-dimensional, computer-assisted navigation reveals superior clinical and radiographic outcomes compared to localization through patient-to-therapist feedback. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: A prospective, randomized, single-blind study was carried out on 50 patients. The population was divided into 2 groups of equal numbers (navigation group and feedback group). In all patients, treatment-resistant pain was evident for longer than 6 months. A total of 3 therapy sessions of constant low-energy focused shock wave therapy was administered in weekly intervals in both groups. Local anesthesia was not applied. Radiographs and clinical assessment, including the Constant and Murley shoulder scoring system and the visual analog scale for pain, were performed both before therapy and after 12 weeks. In the navigation group, the calcium deposit was localized using a radiographically guided, 3-dimensional, computer-assisted device. The feedback group was treated after locating the point of maximum tenderness through palpation by the therapist with feedback from the patient. RESULTS: Both groups had significant improvements in the Constant and Murley score and the visual analog scale after 12 weeks. The results from the navigation group were statistically significantly superior to those of the feedback group. In the navigation group, 6 calcium deposits disappeared and 9 altered, compared to 1 disappearance and 12 alterations in the feedback group. No severe complications occurred. CONCLUSION: Three-dimensional, computer-assisted navigation reveals significantly better results and is therefore recommended when extracorporeal shock wave therapy is used in the treatment of calcific tendinitis of the rotator cuff.