Results of the PeRception of femOroaCetabular impingEment by Surgeons Survey (PROCESS).

PURPOSE: Currently, there is a lack of high-level evidence addressing the variety of treatment options available for patients diagnosed with femoroacetabular impingement (FAI). The objective was to determine the current state of practice for FAI in Canada. METHODS: A questionnaire was developed and pretested to address the current state of knowledge among orthopaedic surgeons regarding FAI treatment using a focus group of experts, reviewing prior surveys, and reviewing online guidelines addressing surgical interventions for FAI. The membership of the Canadian Orthopaedic Association (COA) was surveyed through email and mail in both French and English. RESULTS: Two hundred and two surveys were obtained (20 % response rate), of which 74.3 % of respondents manage patients under age 40 with hip pain. Most surgeons (62 %) considered failure of non-operative management as the most important indication for the surgical management of FAI, usually by treating both bony and soft tissue damage (54.4 %). The majority of surgeons were unsure of the existence of evidence supporting the best clinical test for FAI, the use of a diagnostic intra-articular injection for diagnosis of FAI, and for non-operative management of FAI. One in four respondents supported a sham surgery (24.8 %) control arm for a trial evaluating the impact of surgical intervention on FAI. CONCLUSIONS: This survey elucidates areas of research for future studies relevant to FAI and highlights controversial areas of treatment. The results suggest that the current management of FAI by members of the COA is limited by a lack of awareness of high-level evidence.

What does it take to have a high-grade pivot shift?

UNLABELLED: The pivot shift is the most specific clinical test to assess pathological knee joint rotatory laxity following ACL injury. This article attempts to describe the anatomic structures responsible for creating a high-grade pivot shift and their potential role in customizing ACL reconstruction. A review of the literature demonstrates that disruption of the secondary stabilizers of anterior translation of the lateral compartment including the lateral meniscus, anterolateral capsule, and IT band contributes to a high-grade pivot shift in the ACL-deficient knee. The morphology of the lateral tibial plateau, including increased posteroinferior tibial slope and small size, can also contribute to high-grade pivot shift. Factors that may decrease the grade of the pivot shift include medial compartment injury, MCL injury, patient guarding, and osteoarthritis. In conclusion, a high-grade pivot shift in the ACL-deficient knee is often associated with incompetence of the lateral soft tissue envelope. Rotatory laxity as assessed by the pivot shift may also be falsely underestimated by concomitant injuries. LEVEL OF EVIDENCE: IV.

New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau.

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

[Allografts for cruciate ligament reconstruction]. / Allogene Kreuzbandtransplantation.

Allografts have an essential significance in the surgical reconstruction of ligamentous injuries around the knee joint. While in primary anterior cruciate ligament reconstruction allografts are less important than autografts, at least in the European countries, the usage of allografts in anterior cruciate ligament revision surgery is increasing. In addition, allografts represent a good alternative for the reconstruction of the posterior cruciate ligament and the posterolateral structures. Especially in multiligament reconstructions of the knee joint, the usage of allografts may prevent iatrogenic damage of the already traumatized periarticular soft tissue. The present article focuses on the application and clinical results of allografts for ligament reconstruction around the knee joint. Furthermore, the immunological and biological principles of tendon allografts, their availability, processing, and security are discussed.

Management of the acute knee dislocation: the Pittsburgh experience.

Traumatic dislocation of the knee is among the most severe form of ligament injury to the lower extremity. While the incidence of knee dislocations is low, this injury is associated with a high rate of complications including amputation. There is potential for a traumatic knee dislocation to present to the emergency department after spontaneous or in-field reduction. This requires a vigilant, comprehensive, and systematic approach to the injured knee and extremity to avoid limb-threatening oversights. At the University of Pittsburgh a comprehensive algorithm has been developed to facilitate accurate and efficient diagnosis and treatment of complex traumatic knee injuries. The following manuscript includes a detailed review of the literature and explains our specific approach to this diagnostic dilemma.

[A comparison of orthopaedic sports medicine education in Germany and the US]. / Ein Vergleich der sportorthopädischen Ausbildung in Deutschland und den USA.

INTRODUCTION: The international exchange of German doctors especially in the US makes it important to compare both educational systems. The goal of this article is to discuss the differences and similarities between the German and US American curricula for Orthopaedic Sports Medicine. METHODS: The German and US American curricula for Sports Medicine and their education and fellowship programs were compared. RESULTS: The title 'Specialist for Sports Medicine' can be obtained in both countries. In Germany the curriculum is not speciality specific but offers a general Sports Medicine education that can be obtained through courses or fellowships. In the US this title can be obtained in two different ways, either through the American Board of Family Medicine (ABFM), or the American Board of Orthopaedic Surgery (ABOS) and their respective fellowship programs. DISCUSSION: The Sports Medicine curriculum in Germany and in the US is different with a general Sports Medicine program in Germany and a specific Sports Orthopaedic program in the US.

[Orthopaedic surgery residency: comparison between the German and the North American system]. / Orthopädisch-unfallchirurgische Facharztweiterbildung im deutschen und US-amerikanischen Vergleich.

AIM: On the way to the unification of the European Union (EU), Germany has passed a new medical professional education system at the 106 (th) German medical board in Cologne in 2003. The medical board has established a new residency programme for the specialty of orthopaedic surgery, which was previously separated into orthopaedic and trauma surgery. An exchange of orthopaedic surgeons within the EU is therefore less complicated. For an exchange outside the EU, an international comparison especially with the USA is warranted. METHOD: We analysed and compared the German "Assistenzarzt System" with the residency programme of the USA regarding the specialty of orthopaedic surgery and further sub-specialisation programmes. RESULTS: After evaluation of both systems, a high conformity in the basic training for orthopaedic surgery was demonstrated. However, there is a difference between the two systems regarding specialisation after residency training with the German "Oberarzt" on the one side and the American fellow system on the other side. CONCLUSION: This study demonstrates that the German orthopaedic training matches well with the American residency programs. There is potential for acknowledgement of the German title "Orthopaedic surgeon" in the USA. In some states, such as Pennsylvania, European medical specialists are given institutionally restricted work permission for limited periods of time. It remains, however, questionable if there is a general political intent for the USA to acknowledge German or European residency programs.

ACL reconstruction using bone-patellar tendon-bone press-fit fixation: 10-year clinical results.

Multiple techniques for anterior cruciate ligament (ACL) reconstruction are currently available, most of which use hardware or resorbable material for fixation of the graft inside or outside the bony tunnels. In this study, the long-term results of 95 patients at a mean follow-up of 10.7 years were assessed. The ACL was reconstructed using a patellar tendon autograft with a press-fit fixation. Between 1987 and 1991, 159 patients were operated by the senior author (PH), 95 could be seen for follow-up. Evaluation included detailed history, physical examination, functional knee ligament testing, KT-1000 arthrometer testing, the IKDC standard evaluation form, Lysholm, Flandry, and Tegner scoring systems. Radiographs were obtained preoperatively and at follow-up to assess the grade of osteoarthritis. Subjectively, none of the patients that were seen for follow-up complained of instability. Numbness of the skin was reported by 54% of the patients and pain during knee walking was described as mild in 25% and severe in 2%. The mean Flandry score was 243 (max: 280). The mean Lysholm score was 93.2 at follow-up and the Tegner activity level was 6.8 preinjury and 6.0 postoperatively. The average KT-1000 side-to-side difference was 1.8 mm on a manual maximum pull. The IKDC knee scoring revealed 84% of the patients with normal (A) or nearly normal (B) knee joints, 15% were (C), 1% was (D). Radiographically, joint space narrowing was found in 19%, 15%, and 25% for the patello-femoral, medial, and lateral compartments, respectively. Meniscus surgery was a determining factor. This study presents long-term clinical data on a press-fit fixation for ACL reconstruction. Results were excellent and good in more then 80% of the followed patients. The advantages of the press-fit fixation are direct bone-to-bone healing of the graft, decreased donor site morbidity, cost-effectiveness and ease for revision surgery.

[Biomechanical tests for type II SLAP lesions of the shoulder joint before and after arthroscopic repair]. / Biomechanische Untersuchungen zur Typ-2-SLAP-Läsion am Schultergelenk vor und nach arthroskopischen Repair.

Superior labral anterior-to-posterior (SLAP) lesions can cause shoulder pain partly by causing glenohumeral instability. The purpose of this study was to examine the effect of a simulated type II SLAP lesion and subsequent repair on glenohumeral translation of the vented shoulder. In eight cadaver joints, a robotic/UFS testing system was used to measure joint translation by applying an anterior, posterior, or inferior load of 50 N to each shoulder. The "apprehension tests" for anterior and posterior instability were simulated by applying an anterior load of 50 N with an external rotation torque of 3 Nm or a posterior load of 50 N with an internal rotation torque of 3 Nm. Each loading condition was applied at 30 degrees and 60 degrees of glenohumeral abduction with a constant joint compressive load (44 N) to the intact, simulated SLAP lesion, and repaired shoulder. Repair of the type II SLAP was then performed by placing a Suretac through the labrum both anterior and posterior to the biceps anchor and testing was repeated. ANOVA was used to compare translation of the intact joint, the joint after the type II SLAP lesion had been simulated, and after repair. At 30 degrees of abduction, anterior translation of the intact vented shoulder joint from anterior loading was 18.7+/-8.5 mm and increased to 26.2+/-6.5 mm after simulation of the type II SLAP lesion ( p< or =0.05). The arthroscopic repair did not restore anterior translation (23.9+/-8.6 mm) to the same degree as the intact joint ( p> or =0.05). At 60 degrees of abduction, anterior translation of 16.6+/-9.6mm in the intact joint was not significantly increased at 19.4+/-10.1 after simulation of the type II SLAP lesion ( p=0.0527). AP loading also resulted in inferior translation. At 30 degrees of abduction it was 3.8+/-4.0 mm in the intact joint and increased to 8.5+/-5.4 mm after the type II SLAP lesion ( p< or =0.05. After repair the inferior translation decreased significantly to 6.7+/-5.3 mm ( p< or =0.05). Although inferior translations were less at 60 degrees of abduction, results were similar to those at 30 degrees after repair. There were no significant increases in translation after SI/AP combined external rotation torque or posterior-anterior combined internal rotation torque loading. In this study the repair of a type II SLAP lesion only partially restored translations to the same degree as an intact vented shoulder joint. Therefore, improved repair techniques or an anteroinferior capsulolabral procedure in addition to the type II SLAP lesion repair might be needed to restore normal joint function.

Precision of ACL tunnel placement using traditional and robotic techniques.

The objective of this study was to examine the precision of ACL tunnel placement using: (1) CASPAR (orto MAQUET GmbH Co. KG)--an active robotic system, and (2) four orthopedic surgeons with various levels of experience (between 100 and 3,500 ACL reconstructions). The robotic system and each surgeon drilled tunnels for ACL reconstruction in 10 plastic knees (total n = 50) that included a reference cube in the medial aspect of the proximal tibia and distal femur. For the robotic system, the placement of each tunnel was planned preoperatively using custom software and CT data for each femur and tibia. The robotic system then drilled the tunnels in the femur and tibia based on the preoperative plan. For the surgeons, tunnel placement was accomplished using their preferred technique, which was based on the one-incision arthroscopic technique. The distribution of intra-articular points on the tibia was contained within a sphere of radius 2.0 mm (robot system), 2.1 mm (Fellow 1), 2.4 mm (Fellow 2), 3.4 mm (Experienced Surgeon 1), or 2.0 mm (Experienced Surgeon 2). On the femur, no significant differences in the distribution of intra-articular points could be demonstrated between the robotic system (2.1 mm), Fellow 1 (4.5 mm), Fellow 2 (4.1 mm), Experienced Surgeon 1 (2.3 mm), and Experienced Surgeon 2 (3.0 mm). The direction of the tunnels drilled in the femur and tibia was different with the robotic and traditional techniques. However, the robotic system had the most consistent tunnel directions, while the surgeons' tunnels were more dispersed. Variation in surgeon precision of tunnel placement for ACL reconstruction is greater on the femur than the tibia, and this can be correlated with experience. Our data also suggest that the robotic system has the same precision as the most experienced surgeons.

Mobilization of peripheral blood progenitor cells in patients with breast cancer: a prospective randomized trial comparing rhG-CSF with the combination of rhG-CSF plus rhEpo after VIP-E chemotherapy.

Peripheral blood progenitor cells (PBPC) can be mobilized by chemotherapy, cytokines, or the combination of both. Recently, data from two non-randomized studies were published, showing an advantage for a combination of rhG-CSF plus rhEpo compared to rhG-CSF alone in mobilization of PBPC. To address this question we initiated a prospective, randomized trial in patients with breast cancer. Thirty (28 female, two male) of 32 randomized patients were evaluable. After primary surgery, therapy consisted of two cycles of VIP-E chemotherapy followed by high-dose (HD) chemotherapy with VIC. Mobilization and harvest of PBPC followed cycle 2. Group A received 5 microg rhG-CSF/kg body weight (bw) plus 150 IU rhEpo/kg bw. Group B was treated with 5 microg rhG-CSF/kg bw from dl until end of harvest. In the peripheral blood CD34+ cells as well as colony-forming units (CFU) started to rise on d8 with a peak on d10, followed by a decrease. No significant differences were observed between the groups. Furthermore, there was no significant difference with regard to MNC, CD34+ cells BFU-E and CFU-GM in apheresis products. Transplantation of > 1 x 10(6) CD34+ cells/kg bw after HD chemotherapy resulted in normal hematological recovery of all patients. No differences were observed in time to neutrophil or platelet recovery and need for blood product support. In this study addition of rhEpo to our standard mobilization chemotherapy did not result in improved mobilization of PBPC or in clinical benefits after HD chemotherapy.