Late-stage rehabilitation after anterior cruciate ligament reconstruction: A multicentre randomised controlled trial (PReP).

BACKGROUND: At the completion of formal rehabilitation after anterior cruciate ligament reconstruction, functional capacity is only restored in a small proportion of affected individuals. Therefore, the end of formal rehabilitation is not the end of functional rehabilitation. OBJECTIVE: To compare adherence to and effectiveness of a late-stage rehabilitation programme with usual care after anterior cruciate ligament (ACL) reconstruction. METHODS: This prospective, double-blind, multicentre, parallel group, randomised controlled trial, included people aged 18 to 35 years after formal rehabilitation completion (mean [SD] 241 [92] days post-reconstruction). Participants were block-randomised to a 5-month neuromuscular performance intervention (Stop-X group) or usual care (medically prescribed standard physiotherapy, individual formal rehabilitation, home-exercises). All outcomes were measured once/month. Primary outcome was the normalised knee separation distance on landing after drop jump. Baseline-adjusted linear mixed models were calculated. RESULTS: In total, 112 participants (Stop-X: 57; Usual care: 55,) were analysed. Initially, mean (SD) intervention frequency (units/week) was higher in the Stop-X than the Usual care group: 2.65 (0.96) versus 2.48 (1.14) units/week in the first and 2.28 (1.02) versus 2.14 (1.31) units/week in the second month. No between-group*time(*baseline)-differences were found for the primary outcome. Between-group*time-effects favoured the Stop-X-group at 2 months (fewer self-reported knee problems during sport, KOOS-SPORT) (estimate = 64.3, 95 % CI 24.4-104.3 for the Stop-X), more confidence to return to sport (ACL-RSI) (62.4, 10.7-114.2), fewer pain-associated knee problems (KOOS-PAIN) (82.8, 36.0-129.6), improved everyday activity abilities (KOOS-ADL) (71.1, 6.4-135.7), and improved limb symmetry index in the front hop for distance at 3 and 4 months (0.34, 0.10-0.57; 0.31, 0.08-0.54). No between-group*time-effects occurred for kinesiophobia, symptom-associated knee problems or balance hops performance. At the end of the intervention, 79 % of the Stop-X and 70 % of the Usual care participants (p < 0.05) had successfully returned to their pre-injury sport type and level. CONCLUSIONS: The Stop-X intervention was slightly superior to usual care as part of late-stage rehabilitation after ACL-reconstruction. The small benefit might justify its use after formal rehabilitation completion.

The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction. METHODS: In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not. RESULTS: At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers." CONCLUSIONS: The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.

Contributors to self-report motor function after anterior cruciate ligament reconstruction.

Numerous functional factors may interactively contribute to the course of self-report functional abilities after anterior cruciate ligament  (ACL)-reconstruction. This study purposes to identify these predictors using exploratory moderation-mediation models in a cohort study design. Adults with post unilateral ACL reconstruction (hamstring graft) status and who were aiming to return to their pre-injury type and level of sport were included. Our dependent variables were self-reported function, as assessed by the the KOOS subscales sport (SPORT), and activities of daily living (ADL). The independent variables assessed were the KOOS subscale pain and the time since reconstruction [days]. All other variables (sociodemographic, injury-, surgery-, rehabilitation-specific, kinesiophobia (Tampa Scale of Kinesiophobia), and the presence or absence of COVID-19-associated restrictions) were further considered as moderators, mediators, or co-variates. Data from 203 participants (mean 26 years, SD 5 years) were finally modelled. Total variance explanation was 59% (KOOS-SPORT) and 47% (KOOS-ADL). In the initial rehabilitation phase (< 2 weeks after reconstruction), pain was the strongest contributor to self-report function (KOOS-SPORT: coefficient: 0.89; 95%-confidence-interval: 0.51 to 1.2 / KOOS-ADL: 1.1; 0.95 to 1.3). In the early phase (2-6 weeks after reconstruction), time since reconstruction [days] was the major contributor (KOOS-SPORT: 1.1; 0.14 to 2.1 / KOOS-ADL: 1.2; 0.43 to 2.0). Starting with the mid-phases of the rehabilitation, self-report function was no longer explicitly impacted by one or more contributors. The amount of rehabilitation [minutes] is affected by COVID-19-associated restrictions (pre-versus-post: - 672; - 1264 to - 80 for SPORT / - 633; - 1222 to - 45 for ADL) and by the pre-injury activity scale (280; 103 to 455 / 264; 90 to 438). Other hypothesised contributors such as sex/gender or age were not found to mediate the time or pain, rehabilitation dose and self-report function triangle. When self-report function is rated after an ACL reconstruction, the rehabilitation phases (early, mid, late), the potentially COVID-19-associated rehabilitation limitations, and pain intensity should also be considered. As, for example, pain is the strongest contributor to function in the early rehabilitation phase, focussing on the value of the self-report function only may, consequently, not be sufficient to rate bias-free function.

Excellent midterm survival and functional outcomes of a fully hydroxyapatite-coated cementless stem: first results of a prospective multicenter study.

BACKGROUND: The Polarstem (Smith & Nephew, Baar, Switzerland) is a tapered straight stem, an implant with an excellent survival rate. Although the most recent annual report of the National Joint Registry in the United Kingdom also reports excellent survivorship for the cementless Polarstem, no prospective studies have been published focusing on both its efficacy and clinical performance. Therefore, the present study was designed to prospectively evaluate its functional and radiographic outcomes at midterm. METHODS: This prospective observational study conducted at 3 independent orthopaedic hospitals was designed to collect data in patients undergoing cementless primary total hip arthroplasty (THA). A total of 225 total hip arthroplasties (75 at each site) were performed. The predominant diagnosis was primary osteoarthritis. Anteroposterior and lateral radiographs were obtained at each follow-up (3 months, and 1, 3, and 5 years). Survivorship and the Harris Hip Score (HHS) and Western Ontario and McMaster Universities Index (WOMAC) were calculated. RESULTS: Subjects experienced statistically significant improvements from baseline in mean HHS (48.5 to 88.0, P < .01) and WOMAC scores (58.6 to 9.3, P < .01) at all intervals through 5 years. The stem survivorship was 99.6% at 5 years with stem revision due to any reason. There were no observed cases of mechanical failure of the stem or signs of radiographic loosening. CONCLUSIONS: A revision rate of the femoral stem for any reason of 0.4%, as well as good clinical results based on HHS and WOMAC scores, was noted at 5-year follow-up. Therefore, safety and efficacy of the cementless Polarstem at midterm follow-up is confirmed.

Direct incorporation of mesenchymal stem cells into a Nanofiber scaffold - in vitro and in vivo analysis.

Bony defects are a common problem in musculoskeletal surgery. Replacement with autologous bone grafts is limited by availability of transplant material. Sterilized cancellous bone, while being osteoconductive, has limited osteoinductivity. Nanofiber scaffolds are currently used for several purposes due to their capability of imitating the extracellular matrix. Furthermore, they allow modification to provide functional properties. Previously we showed that electrospun nanofiber scaffolds can be used for bone tissue regeneration. While aiming to use the osteoinductive capacities of collagen type-I nanofibers we saw reduced scaffold pore sizes that limited cellular migration and thus colonization of the scaffolds. Aim of the present study was the incorporation of mesenchymal stem cells into the electrospinning process of a nanofiber scaffold to produce cell-seeded nanofiber scaffolds for bone replacement. After construction of a suitable spinning apparatus for simultaneous electrospinning and spraying with independently controllable spinning and spraying devices and extensive optimization of the spinning process, in vitro and in vivo evaluation of the resulting scaffolds was conducted. Stem cells isolated from rat femora were incorporated into PLLA (poly-l-lactide acid) and PLLA-collagen type-I nanofiber scaffolds (PLLA Col I Blend) via simultaneous electrospinning and -spraying. Metabolic activity, proliferation and osteoblastic differentiation were assessed in vitro. For in vivo evaluation scaffolds were implanted into critical size defects of the rat scull. After 4 weeks, animals were sacrificed and bone healing was analyzed using CT-scans, histological, immunhistochemical and fluorescence evaluation. Successful integration of mesenchymal stem cells into the scaffolds was achieved by iteration of spinning and spraying conditions regarding polymer solvent, spinning distance, the use of a liquid counter-electrode, electrode voltage and spinning duration. In vivo formation of bone tissue was achieved. Using a PLLA scaffold, comparable results for the cell-free and cell-seeded scaffolds were found, while the cell-seeded PLLA-collagen scaffolds showed significantly better bone formation when compared to the cell-free PLLA-collagen scaffolds. These results provide support for the future use of cell-seeded nanofiber scaffolds for large bony defects.

The prevalence of a prominent anterior inferior iliac spine.

INTRODUCTION: Impingement of the prominent anterior inferior iliac spine (AIIS) against the femoral neck has recently been described as another type of impingement. The purpose of this study is to provide a distribution of AIIS types using the classification proposed by Hetsroni and thus report on the prevalence of prominent types. MATERIALS AND METHODS: A total of 400 patients were included in the study with an average age 27.3 ± 6.9 years (range 18-40). All patients received a whole-body polytrauma computer tomography (CT) scan in the emergency room (ER) upon arrival. The classification of AIIS proposed by Hetsroni et al., which describes three morphological types, was used. Type II and III were grouped as prominent types. The measurements were performed in all three planes by two examiners. RESULTS: Male to female ratio was 71:29. Type I was observed in 367 (91.7%) patients. Type II was observed in 31 (7.8%) patients and type III was observed in 2 (0.5%) patients, unilaterally. Prominent types were much more prevalent in men (10.5%) than in women (2.6%). The CT assessment demonstrated excellent intra- and interreliability (overall: 0.926, I/II: 0.906, III: 1.000). CONCLUSION: A young population demonstrates a prevalence of a prominent AIIS of 11.5%. Prominent AIIS is more common in men than in women.

Biomechanical and microbiological effects of local vancomycin in anterior cruciate ligament (ACL) reconstruction: a porcine tendon model.

INTRODUCTION: Although there is increasing evidence for the successful use of local vancomycin applied by soaked compresses during ACL reconstruction, there are still little data on its microbiological and biomechanical effects. Furthermore, exact dosage of vancomycin with respect to tendon stability and microbiological effectivity is still unknown. MATERIALS AND METHODS: 63 porcine flexor digitorum profundus tendons were harvested under sterile conditions from fresh cadaver legs. After contamination with Staphylococcus epidermidis (S. epidermidis), tendons were wrapped into sterile compresses moistened with different concentrations of vancomycin for 10 or 20 min. Sterile sodium chloride was used for control. After treatment, tendons were rolled onto blood-agar plates to test for residual bacterial contamination and tested for maximum load and stiffness using a uniaxial testing device with cryo-clamps for tendon fixation. Agar plates were checked after 1 week of culture at 36 °C for signs of bacterial growth. RESULTS: When applying vancomycin for only 10 min, bacterial contamination was found in all dosage groups ranging from 28.6% contamination (n = 2 of 7 tendons) when using 10 mg/ml up to 85.7% (n = 6 of 7 tendons) when using 1 mg/ml. Applying vancomycin-soaked compresses for 20 min, bacterial contamination was still found in the groups using 1 mg/ml and 2.5 mg/ml (contamination rate 85.7 and 42.9% respectively). When using 5 mg/ml and 10 mg/ml, no bacterial contamination could be perceived after 7 days of culture. With regard to biomechanical properties, no differences were found regarding maximum load or Young's modulus between groups. CONCLUSIONS: This study showed no signs of biomechanical impairment of porcine flexor tendons after the use of vancomycin wraps with concentration ranging from 1 to 10 mg/ml for 10 or 20 min at a time zero testing. Contamination with S. epidermidis was cleansed in 100% of tendons when using at least 5 mg/ml of vancomycin for 20 min.

Predictors for secondary patellar resurfacing after primary total knee arthroplasty using a "patella-friendly" total knee arthroplasty system.

PURPOSE: Patellar resurfacing (PR) in total knee arthroplasty (TKA) is still one of the major controversies in orthopaedic surgery today. The aim of the present retrospective case-control study was to identify predictors for secondary patellar resurfacing (SPR) after initial TKA to create a rationale for surgeons to decide which patients to resurface primarily. It was hypothesized that proper TKA implantation and component positioning as well as a maintained physiological patellar geometry will lead to a reduced risk of SPR. Overmore, it was hypothesized that intrinsic factors like overweight might also have an influence on the need for SPR. METHODS: After identification of suitable patients and age/sex matching in a 1:2 fashion, 29 cases (TKA/SPR) and 58 controls (TKA) were included and screened for available clinical and epidemiological data as well as for radiographic data after primary TKA. Pearson's correlation analysis as well as logistic regression modeling was performed to identify possible predictors for SPR following TKA. RESULTS: Binary logistic regression was able to correctly classify 88.5% of patients into case or control groups. It indicated that patella tilt, patella height, and thickness as well as the delta angle were significant predictors of a need for SPR following primary TKA. An increase in patellar width by 1 mm will increase the risk of SPR, while an increase in patellar thickness by 1 mm will reduce it. An increase in patellar tilt by 1° will also increase the risk of SPR. Finally, an increase in delta angle by 1° will again reduce the risk of SPR. CONCLUSIONS: Easy and accessible radiographic measurements have been identified as possible predictors of SPR following primary TKA. Although indication for primary PR may still remain a controversial topic, a rationale has been proposed in this study to support surgeons in objectively estimating an individual patient's risk for SPR prior to primary TKA measuring the patella tilt, width, and thickness. Overmore, regarding surgical aspects of TKA, tibial component positioning has also been shown to be of importance to reduce the risk of SPR.

Cell-free cartilage repair in large defects of the knee: increased failure rate 5 years after implantation of a collagen type I scaffold.

INTRODUCTION: Cartilage defects of the knee remain a challenging problem in orthopedic surgery despite the ongoing improvements in regenerative procedures such as the autologous chondrocyte transplantation. Due to the lack of donor-site morbidity and the single-stage procedure cell-free scaffolds are an interesting alternative to cell-based procedures. But as currently mid- and long-term data are lacking, the aim of the present study was to present mid-term clinical, radiological and histological results of a cell-free collagen type I scaffolds for cartilage repair. MATERIALS AND METHODS: Twenty-eight patients were followed prospectively. Clinical evaluation using patient-reported outcome measures (KOOS, IKDC; VAS for pain, Tegner score for activity) as well as radiologic evaluation of the repair tissue (MOCART) was performed at 1 year, 2 years and 5 years. Histologic evaluation of the repair tissue was done in case of revision surgery using the ICRS II score for human cartilage repair. RESULTS: In these large cartilage defects with a mean defect size of 3.7 ± 1.9 cm2, clinical failure necessitating revision surgery was seen in 5 of 28 patients (18%). While the remaining patients showed good-to-excellent clinical results (KOOS, IKDC, VAS, Tegner), the radiologic appearance of the repair tissue showed a reduction of the MOCART score between the 2- and 5-year follow-up. Histologic evaluation of the repair tissue showed a cartilage-like appearance with no signs of inflammation or cell death but an overall medium tissue quality according to the ICRS II Score. CONCLUSION: The use of this cell-free collagen type I scaffold for large defects showed increased wear of the repair tissue and clinical failure in 18% of cases at 5-year follow-up.

Transfusions increase complications and infections after hip and knee arthroplasty: An analysis of 2760 cases.

BACKGROUND: Knee and hip replacement surgery are still the mainstay therapy for osteoarthritis. In spite of the improvement of techniques and implants, anemia is a relatively common complication, with transfusion rates of up to 23% in some centers. OBJECTIVE: The purpose of the study was to determine a correlation of transfusions to complications including infection since this topic is still being debated or even disputed in the literature. METHODS: This is a level III, single center retrospective observational cohort study of 2760 unilateral primary knee and hip replacements. Preoperative assessment, the number of transfusions and the occurrence of complications were collected and the correlations were analyzed using analysis of variance and logistic regression. RESULTS: Fifteen percent of all patients developed at least one complication. Transfusion rate was 9%. Risk factors for receiving a transfusion were female gender, hip replacement, American Society of Anesthesiologists' Score (ASA) > III, history of myocardial infarction, chronic cardiac disease, diabetes mellitus, chronic kidney disease, and length of surgery. The risk factors for developing a complication were: ASA score, presence of chronic renal insufficiency, and transfusion during hospital stay. Transfusion increases the risk of complications and infection rate. Complication rate with transfusion was 34.7% and without transfusion 13.2%. Infection rate without transfusion was 0.4% and with transfusion 2.82%. CONCLUSIONS: The complication rate is higher in transfused patients. The number of complications rises linearly with the number of transfusions. Infection rate is also higher after a transfusion. Efforts should be made to reduce the transfusion rate.

The effect of surgeon's learning curve: complications and outcome after hip arthroscopy.

INTRODUCTION: The aim of the present study was to determine the incidence and type of complications during and after hip arthroscopy as well as the effect of the surgeon's learning curve on the occurrence of complications. We expect that the currently reported prevalence especially of minor complications is likely to be underreported in most retrospective series based on chart analysis. MATERIALS AND METHODS: The study included all consecutive patients who underwent hip arthroscopy between 2006 and 2014 at a minimum follow-up of 6 weeks starting with the first patient undergoing hip arthroscopy at the institution. Patient outcome was evaluated using the WOMAC score, VAS for pain, SF-36 questionnaire and the hip-outcome score. Additionally, intra- and postoperative complications were recorded via a questionnaire and additional review of patient files. RESULTS: We identified 529 patients who underwent hip arthroscopy between 2006 and 2014. Complete data could be gathered from 485 patients (91.7%). Major complications occurred in three patients (0.6%; fractures of the femoral neck requiring surgical treatment in one case). Minor complications that did not require further intervention were self-limiting postoperative temporary neurapraxia, hematoma, self-limiting dyspareunia, deep vein thrombosis and impaired wound healing, with hematoma and temporary paresthesia due to traction neurapraxia being the most common ones (22.5 and 16.4% respectively). The overall re-operation rate was 15.7% with conversion to total hip arthroplasty being the most common (11.9%). CONCLUSIONS: The overall major complication rate was low and thus hip arthroscopy can be rated as a safe procedure. But minor complications such as hematoma and temporary paresthesia due to traction neurapraxia are common and currently underreported. Surgeons' learning curves show a reduction of major complications once 60 procedures per surgeon per year is surpassed.

Femoral tunnel widening is associated with tunnel malposition but not with clinical failure after medial patellofemoral ligament reconstruction with a free gracilis tendon graft.

INTRODUCTION: MPFL reconstruction is widely and successfully used for treating patella instability, either as a standalone procedure or in combination. Although different techniques allow for MPFL reconstruction, the use of a free tendon graft is one of the most commonly used. The phenomenon of tunnel widening or tunnel enlargement is well described in ACL reconstruction, but so far only little effort has been put into evaluating this phenomenon after MPFL reconstruction. MATERIALS AND METHODS: Patients who received an MPFL reconstruction with a free gracilis tendon graft were identified by review of patient files. Additional clinical examination and magnetic resonance imaging were performed to assess tunnel enlargement and clinical outcome. RESULTS: Fifty-one knees of 49 patients (34 female, 17 male) with a mean follow-up of 3.0 ± 1.4 years were included in this study. Mean age at the time of surgery was 22.6 ± 8.5 years. Mean Tegner score decreased from preoperative 5.3 ± 2.0 to 4.0 ± 1.4 postoperative. Postoperative IKDC and Kujala scores were 74 ± 16 and 80 ± 15, respectively. Twenty-three patients showed a tunnel enlargement at follow-up examination. Of these 23 patients, 20 showed a tunnel that was positioned too proximal, whereas only 13 of the 28 patients showing no enlargement had a tunnel that was positioned too proximal (p = 0.0033). Interestingly, patients showing a tunnel enlargement at follow-up examination also showed significantly better Kujala (84 ± 12 vs. 75 ± 16; p = 0.03) and IKDC scores (80 ± 7 vs. 70 ± 19; p = 0.02) when compared to the non-enlarged group. CONCLUSION: Tunnel enlargement after MPFL reconstruction with a free gracilis tendon graft seems to be connected to mechanical overload due to a proximal malposition of the femoral tunnel. Interestingly, this did not influence clinical outcome as patients with tunnel enlargement showed better Kujala and IKDC scores.

Back to Sports After Arthroscopic Revision Bankart Repair.

BACKGROUND: Recurrent instability following primary arthroscopic stabilization of the shoulder is a common complication. Young, athletic patients are at the greatest risk of recurring instability. To date, the literature contains insufficient description regarding whether return to sports is possible after revision arthroscopic Bankart repair. HYPOTHESIS: Patients presenting with recurrent instability after primary arthroscopic stabilization should expect limitations in terms of their ability to partake in sporting activities after revision surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty athletes who underwent arthroscopic revision stabilization of the shoulder after failed primary arthroscopic Bankart repair were included in the study after completing inclusion and exclusion criteria surveys. Athletic Shoulder Outcome Scoring System (ASOSS), Shoulder Sport Activity Score (SSAS), and the Subjective Patient Outcome for Return to Sports (SPORTS) scores were determined to assess the participants' ability to partake in sporting activities. Furthermore, sport type and sport level were classified and recorded. To assess function and stability, Rowe, American Shoulder and Elbow Surgeons, Constant-Murley, and Walch-Duplay scores were measured and recorded. RESULTS: Follow-up consultations were carried out after a mean of 28.7 months. The mean age at follow-up examination was 27.75 years. At the time of follow-up, 70% of the patients were able to return to their original sporting activities at the same level. However, 90% of patients described a limitation in their shoulder when participating in their sports. At 28.7 months after surgery, the mean ASOSS score was 76.8; the SSAS score decreased from 7.85 before first-time dislocation to 5.35 at follow-up (P < .005). The SPORTS score was 5.2 out of 10 at the follow-up consultation. Function- and instability-specific scores showed good to excellent results. The mean external rotational deficit for high external rotation was 9.25°, and for low external rotation it was 12°. CONCLUSION: Patients can return to their original type and level of sport after arthroscopic revision Bankart repair, but they must expect persistent deficits and limitations to the shoulder when put under the strains of sporting activity. Patients with shoulder injuries who partake in sports that put greater demand on the shoulder show the smallest probabilities of returning to sporting activity.

The effect of ankle tape on joint position sense after local muscle fatigue: a randomized controlled trial.

BACKGROUND: Ankle tape is widely used by athletes to prevent ankle sprain. Although there is growing evidence that ankle tape improve joint position sense, but yet it is not clear even if tape improve joint position sense after muscle fatigue, because fatigue impair joint position sense and raise the risk of ankle sprain. The aim of this study is to examine the effect of ankle tape on joint position sense after local muscle fatigue. METHOD: This trial is a randomized controlled trial. 34 healthy subjects participated in this trial. Subjects were randomized distributed into two groups: with tape and without tape. Active and passive absolute error and variable error mean values for two target positions of the ankle joint (15° inversions and inversion minus 5°) before and after fatigue protocol consisted of 30 consecutive maximal concentric/concentric contractions of the ankle evertors and invertors. In this trail joint position sense for all subjects was assessed using The Biodex System isokinetic dynamometer 3, this system is used also for fatigue protocol. RESULTS: For the variable error (VE), significant mean effect was found for active joint position sense in 15° of inversion after muscle fatigue (P < 0, 05). It was a significant decrease in the work in the last third of inversion detected (P < 0, 05). There was no significant main effect found for fatigue index of eversion. CONCLUSION: Ankle tape can improve joint position sense at the fatigue session when joint position sense becomes worse. As a result, ankle tape may be useful to prevent ankle sprain during playing sports. We suggest athletes and individuals at risk of ankle sprain to apply taping before high-load activity. TRIAL REGISTRATION: The study was retrospectively registered on the ISRCTN registry with study ID ISRCTN30042335 on 12th December 2017.

Rotator cuff muscular integrity after arthroscopic revision of a Bankart repair.

INTRODUCTION: Recurrent shoulder instability after arthroscopic Bankart repair is still a common complication. For primary Bankart repair studies have shown that the rotator cuff can recover completely. The ability of muscles to regenerate after arthroscopic revision Bankart repair (ARBR) has not been studied. Does the ARBR using a three-portal method allows complete muscle integrity compared with an uninjured imaging control group (ICG)? MATERIALS AND METHODS: Twenty-two (1 female, 21 males) physically active patients (mean age at follow-up 28.5 ± 7.1 years; mean follow-up 27.5 months ± 8.5) were assessed. ARBR with a three-portal method was carried out in all patients according to previous primary arthroscopic stabilization of the shoulder (revision Bankart group). Muscle atrophy of the subscapularis muscle (SSC), supraspinatus muscle (SSP) and infraspinatus muscle (ISP) was assessed by making lateral and vertical measurements by magnetic resonance imaging (MRI). Fatty infiltration was detected by standardized assessment from variations in intensity. Detailed clinical examination of the rotator cuff was carried out. MRI assessment was compared with that of a control group of 22 healthy volunteers of same age and activity level (ICG). RESULTS: For the SSC, no muscle impairment was noted compared with the ICG [superior atrophy index (sAISSC), p = 0.439; inferior atrophy index (iAISSC), p = 0.555; superior fatty infiltration index (sFDISSC), p = 0.294; inferior fatty infiltration index (iFDISSC), p = 0.62]. In investigation of the SSP and ISP, fatty infiltration was not shown (FDISSP, p = 0.454; sFDIISP, p = 0.504), though persistent muscle atrophy was found even > 2 years after surgery compared with the ICG (AISSP, p = 0.0025; sAIISP, p = 0.0009; iAIISP, p = 0.0004). CONCLUSION: ARBR using a three-portal method allowed good muscular integrity compared with the ICG, but with persistent slight muscular atrophy of the SSP and ISP.

[A Novel Technique for the Preparation of a 3- or 5-Stranded Hamstring Graft for Individualised Single-Bundle ACL or PCL Reconstruction]. / Neuartige Technik zur Präparation eines 3- oder 5-strängigen Hamstring-Transplantats für die individualisierte Single-Bundle-VKB- oder -HKB-Rekonstruktion.

Objective Development of a preparation technique for hamstring tendons to ensure a maximum of intraoperative flexibility during individualised cruciate ligament surgery. Indications Primary ACL- and PCL-reconstruction as well as cases of later revision. Method Three- or five-stranded grafts can be obtained with the use of semitendinosus and gracilis tendons with fiber tape enforcement and use of a conventional femoral cortical suspensory fixation device. Fibre tape and knotting style ensure free motion of the continous loop. Through its simplicity, the technique offers the highest grade of intraoperative scalability.

Anatomic dissection of the anterolateral ligament (ALL) in paired fresh-frozen cadaveric knee joints.

INTRODUCTION: Different dissection studies as well as comparative studies about the anterolateral ligament of the knee (ALL) already exist and the structure's topology and properties have been shown. However, most of the studies investigating the ligament were performed in embalmed knees, which is thought to change the structural integrity of ligaments and thus the topologic and dynamic measurements. Since the biomechanical function of the ALL is not fully understood until today and a correlation with the pivot shift phenomenon is yet speculative, further studies will have to clarify its definitive importance. Its function as a limiter of internal rotation and lateral meniscal extrusion leads to the assumption of a secondary knee stabilizer. METHODS: Twenty paired fresh-frozen cadaveric knees of ten donors have been dissected in a layerwise fashion. After identification of the ALL, topologic measurements were undertaken using a digital caliper. RESULTS: The ALL could be identified as a tender, pearly structure in front of the anterolateral joint capsule in only 60% of the dissected knee joints. Only 20% of donors had a bilateral ALL while 80% had an ALL only in one side. Mean length, thickness and width as well as topographic measurements were comparable to other available studies investigating fresh-frozen cadavers. CONCLUSION: Anatomy and topography of the ALL seem to be highly variable, but consistent within certain borders. Prevalence has to be argued though as it strongly differs between studies. The impact of an ALL absence, even if only unilateral, needs to be investigated in clinical and imaging studies to finally clarify its importance.

Implementation and effects of pulse-contour- automated SVV/CI guided goal directed fluid therapy algorithm for the routine management of pancreatic surgery patients.

BACKGROUND: Goal directed fluid management in major abdominal surgery has shown to reduce perioperative complications. The approach aims to optimize the intravascular fluid volume by use of minimally invasive devices which calculate flow-directed variables such as stroke volume (SV) and stroke volume variation (SVV). OBJECTIVE: We aimed to show the feasibility of routinely implementing this type of hemodynamic monitoring during pancreatic surgery, and to evaluate its effects in terms of perioperative fluid management and postoperative outcomes. METHODS: All patients undergoing pancreatic surgery at a university hospital during two successive 12 months periods were included in this retrospective cohort analysis. Twelve months after the implementation of a standard operating procedure for a goal directed therapy (GDT, N = 45) using a pulse contour automated hemodynamic device were compared with a similar period before its use (control, N = 31) regarding mortality, length of hospital and ICU stay, postoperative complications and the use of fluids and vasopressors. RESULTS: Overall, 76 patients were analysed. Significantly less crystalloids were used in the GDT group. Patients receiving GDT showed significantly fewer severe complications (insufficiency of intestinal anastomosis: 0 vs. 5 (P = 0.0053) and renal failure: 0 vs. 4 (P = 0.0133). Mortality for pancreatic surgery was 1 vs. 3 patients, (P = 0.142), and length of stay (LOS) in the intensive care unit (ICU) was 4.38 ± 3.63 vs. 6.87 ± 10.02 (P= 0.0964) days. Use of blood products was significantly less within the GDT group. CONCLUSIONS: Implementation of a SOP for a GDT in the daily routine using flow-related parameters is feasible and is associated with better outcomes in pancreatic surgery.

Midterm follow-up after implantation of a polyurethane meniscal scaffold for segmental medial meniscus loss: maintenance of good clinical and MRI outcome.

PURPOSE: The preservation of meniscal structure and function after segmental meniscal loss is of crucial importance to prevent early development of osteoarthritis. Implantation of artificial meniscal implants has been reported as a feasible treatment option. The purpose of this study was to assess the clinical and magnetic resonance imaging (MRI) results 4 years after implantation of a polyurethane scaffold for chronic segmental medial meniscus deficiency following partial medial meniscectomy. METHODS: Eighteen patients received arthroscopic implantation of an Actifit(®) polyurethane meniscal implant (Orteq Sports Medicine, London, UK) for deficiency of the medial meniscus. Patients were followed at 6, 12, 24, and 48 months. Clinical outcome was assessed using established patient-reported outcome scores (KOOS, KSS, UCLA Activity Scale, VAS for pain). Radiological outcome was quantified by MRI scans after 6, 12, 24, and 48 months evaluating scaffold morphology, tissue integration, and status of the articular cartilage as well as signs of inflammation. RESULTS: Median patient age was 32.5 years (range 17-49 years) with a median meniscal defect size of 44.5 mm (range 35-62 mm). Continuing improvement of the VAS and KSS Knee and Function Scores could be observed after 48 months compared to baseline, whereas improvement of the activity level according to UCLA continued only up to 24 months and decreased from there on. The KOOS Score showed significant improvement in all dimensions. MRI scans showed reappearance of bone bruises in two patients with scaffold extrusion. No significant changes in the articular cartilage could be perceived. CONCLUSION: Arthroscopic treatment for patients with chronic segmental meniscal loss using a polyurethane meniscal implant can achieve sustainable midterm results regarding pain reduction and knee function. LEVEL OF EVIDENCE: IV.