Handedness-related outcome following arthroscopic shoulder stabilization.

INTRODUCTION: Bankart's repair technique represents a standard procedure for arthroscopic shoulder stabilization with excellent functional outcomes. Information concerning handedness-related outcome is missing. Here, we compare the postoperative outcome following arthroscopic shoulder stabilization in relation to handedness, taking sex and age as covariates into account. PATIENTS AND METHODS: Our retrospective dual-cohort study included 36 patients with dominant side shoulder instability (mean follow-up 33 months) and 31 patients with non-dominant side shoulder instability (mean follow-up 41 months), who underwent arthroscopic shoulder stabilization due to traumatic anterior-inferior shoulder instability. All had experienced recurrent dislocations preoperatively. The impact of handedness, and of age and sex as covariates on postoperative outcome was evaluated by the Rowe score, the apprehension test and self-reported VAS. RESULTS: Postoperatively, the Rowe score of the dominant side (mean 81.8, median 97.5) and the non-dominant side (mean 84.8, median 100) was not different (P = 0.718). Likewise, the univariate analysis for handedness (P = 0.806), sex (P = 0.627) and age (P = 0.929) as well as multivariate analysis for handedness (P = 0.721), sex (P = 0.583) and age (P = 0.898) showed no difference. The apprehension test for dominant versus non-dominant side operated patients was not different (P = 0.194). The univariate and multivariate analysis for handedness (P = 0.202 and P = 0.387, respectively) and age (P = 0.322 and P = 0.310, respectively) revealed no difference. However, the univariate and multivariate analysis for sex (P = 0.007 and P = 0.013, respectively) showed a difference. In relation to handedness, the results for the validated self-reported pain (rest pain P = 0.696, load-dependent pain P = 0.332) and surgery outcome satisfaction (P = 0.912) VAS were not different. CONCLUSIONS: Patients with shoulder instability, who underwent arthroscopic Bankart repair for stabilization of their dominant or non-dominant shoulder showed no handedness-related difference in postoperative outcome based on Rowe score, apprehension test and self-reported VAS. For the orthopedic practice, this suggests that handedness is not a risk factor for patients outcome. LEVEL OF EVIDENCE: Level IV, cohort study.

Clostridial Infection After Open Fractures of the Lower Extremity - Report of Two Cases and Discussion of Pathomechanism and Treatment.

BACKGROUND: Management of post-traumatic open fractures resulting from severe injuries of the lower extremity continues to challenge orthopedic and reconstructive surgeons. Moreover, post-traumatic osteoarticular infections due to Clostridium species are rare, with few reports in the literature. We describe possible pathomechanisms and propose treatment options for cases of delayed diagnosis of osteoarticular infections with Clostridium spp. CASE REPORTS: Two patients sustained severe osteoarticular infection due to Clostridium spp. after open epi- and metaphyseal fractures of the lower extremity. In combination with radical debridement, ankle arthrodesis and long-term antibiotic treatment, satisfactory results were achieved after a follow-up of 18 months and 24 years. CONCLUSION: Clostridium species are difficult to identify, treatment is usually delayed and most patients have unfavourable outcomes.

A biomechanical comparison of two plating techniques in lateral clavicle fractures.

BACKGROUND: Neer Type IIb lateral clavicle fractures typically lead to dislocation of the medial fragment. Therefore, most surgeons recommend surgical treatment for such a fracture pattern. The use of a locking compression plate with a lateral extension has produced satisfactory results in various studies over recent years. Double-plate fixation is a common technique in the treatment of complex distal radius fractures. The authors use this technique as a routine procedure in the treatment of Neer type IIb fractures. In this biomechanical testing study, the mechanical properties of the two techniques were compared. METHODS: On 20 clavicles from fresh frozen cadavers a Neer Type IIb fracture-like osteotomy was performed. A cyclic loading test followed by a load-to-failure test was carried out. Parameters for statistical evaluation were the stiffness at cycles 1, 100 and 17,500 as well as the ultimate tensile load and the deformation at the point of failure. FINDINGS: All specimens withstood the cyclic loading test without any noticeable damage. At cycles 100 and 17,500, the double-plate technique was less stiff. Failure loads were not significantly different from each other, but deformation at the point of failure was significantly greater for the double-plate technique. INTERPRETATION: Both techniques provided sufficient fixation to the fracture site to endure the cyclic loading test, which is supposed to simulate an incident-free week postoperatively. In summary, the double-plate technique offers biomechanically a feasible alternative to the single-plate technique in lateral clavicle fractures of Neer Type IIb.

Injection with autologous conditioned serum has better clinical results than eccentric training for chronic Achilles tendinopathy.

PURPOSE: Chronic Achilles tendinopathy is one of the most common causes of malfunction and pain, which can lead to a significant reduction of the quality of life. The hypothesis of this study argues that autologous conditioned serum (i.e. Orthokine) injections in chronic midportion Achilles tendinopathy have a better outcome than eccentric training. METHODS: This study investigates, retrospectively, the effects of peritendinous autologous conditioned serum injections as compared to standard eccentric training in 50 patients with chronic Achilles tendinopathy between 2012 and 2015. Before injection or eccentric training and 6 weeks, 12 weeks and 6 months thereafter, the patients were assessed by means of the VISA-A-G score (Victorian Institute of Sport Assessment-Achilles questionnaire-German). An MRI was also performed before and 6 months after injection and eccentric training. RESULTS: Both patient groups had statistically significant better VISA-A-G scores after injection or eccentric training compared to the baseline before injection (90 vs 40, respectively, P < 0.001) or eccentric training (81 vs 47, respectively, P < 0.001). Comparing the baseline corrected VISA-A-G scores, patients in the autologous-conditioned-serum-group had significantly higher changes in VISA-A-G scores than the eccentric-training-group after 12 weeks (40 vs 36, P = 0.018) and 6 months (50 vs 34, P = 0.034). Both patient groups had statistically significant (P < 0.001) reduction of tendon thickness (autologous conditioned serum: 0.32; eccentric training: 0.24) and length of bursa (autologous conditioned serum: 0.24; eccentric training: 0.21) as well as significant (P < 0.001) improvement of tendon quality in MRI (autologous conditioned serum: 14 vs 1; eccentric training: 14 vs 2). There were no statistical differences in MRI-findings between the two groups. CONCLUSION: Both therapies led to improvement of MRI-findings, including reduction of tendon thickness and tendon quality. Autologous-conditioned-serum-injections show greater clinical long-term benefit as compared to eccentric training and, therefore, offers a good alternative to eccentric training. LEVEL OF EVIDENCE: Therapeutic studies, Level III.

Response of the Injured Tendon to Growth Factors in the Presence or Absence of the Paratenon.

BACKGROUND: The paratenon is important for Achilles tendon healing. There is much interest in the use of exogenous growth factors (GFs) as potential agents for accelerating the healing of damaged Achilles tendons. PURPOSE/HYPOTHESIS: The present study used a rat model to study the responses of the injured Achilles tendon to GFs in the presence or absence of the paratenon. The hypothesis was that responses of the injured tendon to GFs would be lower in the absence of a paratenon. STUDY DESIGN: Controlled laboratory study. METHODS: A 4-mm defect was created in the right Achilles tendon of 60 skeletally mature rats, which were treated with a validated combination of GFs (bFGF, BMP-12, and TGF-ß1). Animals were randomly assigned to the intact paratenon (IP) group or resected paratenon (RP) group. Healing was studied anatomically, mechanically, and histologically after 1, 2, and 4 weeks. RESULTS: IP tendons showed improved healing compared with RP tendons. IP tendons were significantly stronger (32.2 N and 48.9 N, respectively) than RP tendons (20.1 N and 31.1 N, respectively) after 1 and 2 weeks. IP tendons did not elongate as much as RP tendons and had greater cross-sectional areas (18.0 mm2, 14.4 mm2, and 16.4 mm2, respectively) after 1, 2, and 4 weeks compared with RP tendons (10.5 mm2, 8.4 mm2, and 11.9 mm2, respectively). On histology, earlier collagen deposition and parallel orientation of fibrils were found for IP tendons. CONCLUSION: The paratenon is essential for efficient Achilles tendon healing. Healing with GFs in this Achilles tendon defect model was superior in the presence of the paratenon. CLINICAL RELEVANCE: Biological approaches to tendon engineering using GFs are in vogue and have been shown to improve healing of the rat Achilles tendon, most likely by inducing progenitor cells located within the paratenon. Clinically, resection or incision of the paratenon has been proposed for wound closure. Our data demonstrate the fundamental importance of the paratenon, which therefore should be preserved during Achilles tendon repair, especially if augmented with products such as platelet-rich plasma or autologous conditioned serum that are rich in GFs.

The Role of the Paratenon in Achilles Tendon Healing: A Study in Rats.

BACKGROUND: The role of the paratenon in tendon healing is unknown. The present study compares healing in the presence or absence of the paratenon in an Achilles tendon defect model in rats. HYPOTHESIS: Resection of the paratenon impairs tendon healing. STUDY DESIGN: Controlled laboratory study. METHODS: Sixty skeletally mature Sprague Dawley rats were randomly assigned to either a resected paratenon (RP) group or an intact paratenon (IP) group. In all animals, a 4-mm portion of the Achilles tendon was resected in the midsubstance. In the RP group, the paratenon was resected completely. In the IP group, the paratenon was opened longitudinally and closed again after the tendon defect had been created. One, 2, and 4 weeks after surgery, 7 animals per group were tested biomechanically and 3 animals per group examined histologically. RESULTS: The recovery of mechanical strength was much more rapid in IP tendons. Tear resistance was significantly increased for IP tendons (41.3 ± 8.8 N and 47.3 ± 14.1 N, respectively) compared with RP tendons (19.3 ± 9.1 N and 33.2 ± 6.4 N, respectively) after 1 and 2 weeks. The cross-sectional area was larger in the IP group after 1 and 2 weeks (8.2 ± 2.3 mm2 and 11.3 ± 3.1 mm2 vs 5.0 ± 2.4 mm2 and 5.9 ± 2.0 mm2, respectively) compared with the RP group. Tendon stiffness was greater in the IP group after 1 week (10.4 ± 1.9 N/mm vs 4.5 ± 1.6 N/mm, respectively) compared with the RP group. In comparison, normal contralateral tendons had a maximal tear resistance of 56.6 ± 7.2 N, a cross-sectional area of 3.6 ± 0.7 mm2, and stiffness of 17.3 ± 3.8 N/mm. Hematoxylin and eosin staining revealed slightly delayed healing of RP tendons. Early collagen formation was seen in the IP group already after 1 week, whereas in the RP group, this only occurred after 2 weeks. After 4 weeks, the IP tendons showed more collagen crimp formation than the RP tendons. CONCLUSION: An intact paratenon promotes healing of the Achilles tendon. CLINICAL RELEVANCE: Although incision or resection of the paratenon has been advocated when repairing injured or degenerative tendons, our data suggest that the integrity of the paratenon should be preserved.

Comparison of 2 plating techniques for lateral clavicle fractures, using a new standardized biomechanical testing setup.

BACKGROUND: Conservative treatment of lateral clavicle fractures (Neer type II) often ends with unsatisfactory results for patients. Operative treatment is thus gaining acceptance. A retrospective study found success using a double plate technique for these injuries. For the current study, a standardized testing setup was developed to compare the mechanical properties of single versus double plate technique for lateral clavicle fractures. METHODS: Six synthetic bones were tested for each technique. Neer type IIB fractures were created using computer-aided design (CAD). Fatigue testing was carried out with a cantilever bending test. Parameters measured were cycles undergone, failure load and stiffness at the point of failure. RESULTS: The standardized testing setup was able to provide reproducible failures. The double plate technique lasted about 16,000 more cycles and withstood an additional 22.4 N on average. CONCLUSIONS: The new modified standardized testing setup produced reproducible fixation failures for both clavicle fracture fixation techniques. The double plate technique seems to be mechanically superior to the single plate technique.

Follistatin-like protein 1 modulates IL-17 signaling via IL-17RC regulation in stromal cells.

Follistatin-like protein 1 (FSTL-1) possesses several newly identified roles in mammalian biology, including interleukin (IL)-17-driven inflammation, though the mechanism underlying FSTL-1 influence on IL-17-mediated cytokine production is unknown. Using parallel in vitro bone marrow stromal cell models of FSTL-1 suppression, we employed unbiased microarray analysis to identify FSTL-1-regulated genes and pathways that could influence IL-17-dependent production of IL-6 and granulocyte colony-stimulating factor. We discovered that FSTL-1 modulates Il17rc gene expression. Specifically, FSTL-1 was necessary for Il17rc gene transcription, IL-17RC surface protein expression and IL-17-dependent cytokine production. This work identifies a mechanism by which FSTL-1 influences IL-17-driven inflammatory signaling in vitro and reveals a novel function for FSTL-1, as a modulator of gene expression. Thus enhanced understanding of the interplay between FSTL-1 and IL-17-mediated inflammation may provide insight into potential therapeutic targets of IL-17-mediated diseases and warrants ongoing study of in vivo models and clinical scenarios of FSTL-1-influenced diseases.

Operative Techniques For Treatment Of Chronic Massive Rotator Cuff Lesions : Deltoid Flap Transfer Versus Arthroscopic Debridement.

The treatment of chronic massive rotator cuff lesions remains challenging. Extensive reconstruction techniques as deltoid flap transfer as well as low invasive arthroscopic debridement techniques were established and showed good results. In present study 106 patients with massive rotator cuff lesions were treated by deltoid muscle flap transfer (n = 47 group I) and by arthroscopic debridement (n = 59 group II). Postoperative outcome was determined by amount of pain, range of motion, shoulder functionality according to Constant-Murley Shoulder Score and radiological assessment of acromiohumeral distance (AHD). Statistically analysis was done by the T-Test and Mann-Whitney-U-Test. Both groups showed significant improvement of range of motion compared to preoperative situation, but statistical analysis revealed no significant difference between both groups either in flexion or abduction. Overall shoulder functionality increased significantly in group I (30,2 points) and group II (20,6 points) postoperative, however group I improved significantly more in overall functionality compared to group II (p < 0,01). Therefore, present study showed that surgical treatment with arthroscopic debridement or deltoid muscle flap transfer can improve shoulder function in patients with chronic massive rotator cuff lesions. Deltoid muscle flap showed significantly better results in overall shoulder function and seems superior regarding clinical outcome. However, in regard to the good outcome a detailed risk-benefit analysis should be done before a deltoid-flap transfer is performed.

Results of a New Treatment Concept for Concomitant Lesion of Medial Collateral Ligament in Patients with Rupture of Anterior Cruciate Ligament.

Anteromedial knee injury with rupture of anterior cruciate ligament (ACL) and concomitant lesion of medial collateral ligament (MCL) is common in athletes. No standardized treatment concept can be found within the literature. This study presents results of a new treatment concept for concomitant MCL lesions in patients with ACL rupture. In this study, 67 recreational athletes with ACL injury and concomitant MCL lesion were treated according to a distinct treatment concept. Patients were classified in six different types of concomitant MCL lesion depending on grade of MCL lesion and presence of anteromedial rotatory instability (AMRI). Final classification and surgical indication were determined 6 weeks posttraumatic. All patients received ACL reconstruction. MCL was treated by surgical or conservative regime due to type of concomitant MCL lesion. International Knee Documentation Committee (IKDC), AMRI, and Lysholm scores were evaluated both preoperatively and after 6 weeks, 16 weeks, 12 months, and 18 months postoperatively. All patients could be uniquely classified and treated according to the introduced treatment concept. AMRI was verifiable in patients with grade II and III MCL lesions. All patients showed good to excellent clinical results at the follow-up examinations. In all 67 patients (100%), the findings were graded as normal or nearly normal according to the IKDC knee examination form. Lysholm score averaged 93.9 at final follow-up. The introduced treatment concept showed good results on short-term outcome and provides a sufficient treatment strategy for concomitant MCL lesions in athletes with ACL rupture.

Effect of a Simple Collagen Type I Sponge for Achilles Tendon Repair in a Rat Model.

BACKGROUND: Several sophisticated approaches to tendon engineering have been investigated as ways to improve tendon healing with the early formation of repair tissue with possibly a high amount of type I collagen. Besides the new formation of collagen type I, there is evidence for the natural integration of surrounding collagen type I from healthy tendon parts into the healing defect. However, the simple application of a type I collagen sponge to the healing site to increase the amount of local collagen type I has not been investigated. HYPOTHESIS: Healing of the rat Achilles tendon can be accelerated by an additional supply of collagen type I, resulting in increased tear resistance. STUDY DESIGN: Controlled laboratory study. METHODS: The right Achilles tendons of 42 rats were transected. In half of the animals, a type I collagen sponge was placed into the gap. Animals were allowed to move freely in their cages to simulate early functional therapy. After 1, 2, and 4 weeks, tendon length, width, maximal load to failure, and stiffness were measured and the healing site studied histologically according to the Bonar score. Inflammation was evaluated by the appearance of macrophages and neutrophilic and eosinophilic granulocytes. RESULTS: Defects receiving collagen sponges showed improved healing, with significantly stronger (29.5 vs 5.0 N, respectively, at 1 week; P = .00003), shorter (11.6 vs 14.5 mm, respectively, at 4 weeks; P = .005), thicker (10.0 vs 1.8 mm(2), respectively, at 1 week; P = .00002), and less stiff (19.5 vs 30.5 N/mm, respectively, at 4 weeks; P = .02) tendons than control tendons. Overall, the biomechanical properties of the collagen-treated tendons appeared to be significantly closer to those of native, uninjured tendons compared with tendons in the control group. Histologically, no inflammatory reaction due to the collagen sponge was found. CONCLUSION: Tendon healing was accelerated by the type I collagen sponge. Moreover, the mechanical properties of collagen-treated tendons appeared to be significantly closer to those of normal, uninjured tendons compared with control tendons without collagen treatment. CLINICAL RELEVANCE: As a simple type I collagen sponge seems to increase the amount of local collagen type I, the careful use of such sponges might be an option for tendon augmentation during Achilles tendon surgery.

Risk of Noncontact Anterior Cruciate Ligament Injuries Is Not Associated With Slope and Concavity of the Tibial Plateau in Recreational Alpine Skiers: A Magnetic Resonance Imaging-Based Case-Control Study of 121 Patients.

BACKGROUND: Anatomic features of the tibial plateau (ie, posterior slope and medial concavity) have been associated with an increased risk of anterior cruciate ligament (ACL) injuries. However, it remains unclear whether these findings translate to ACL injuries sustained during recreational alpine skiing. PURPOSE: To investigate the association in recreational alpine skiers between prominent morphological features of the tibial plateau (slope and concavity) and the risk of sustaining an ACL injury during a noncontact incident. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Magnetic resonance imaging data of 121 recreational alpine skiers (74 female, 47 male) after a noncontact knee injury were used for this study. Of these patients, 80 (71% female [n = 57]) had a complete unilateral ACL tear (rupture group), and 41 (41% female [n = 17]) had no indications of an ACL injury (intact group). Two blinded independent examiners measured the slopes of the tibial plateau in the sagittal and coronal planes along with the maximum depth of the medial tibial plateau. Measurements were compared between sexes and between groups using t tests. Logistic regression was used to assess the associations between quantified anatomic indices and the risk of ACL injuries. RESULTS: Within 121 study patients, female skiers had greater odds of an ACL tear compared with male skiers (odds ratio, 3.5; 95% CI, 1.6-7.8; P < .001). Female skiers were more likely to have a greater lateral tibial slope (LTS) (P = .02) and medial tibial slope (MTS) (P = .02) with a shallower medial tibial depth (MTD) (P = .02) compared with male skiers. No differences between sexes were observed in the coronal tibial slope (CTS) (P = .97). Male and female skiers as a combined group showed no associations between quantified anatomic indices and the risk of sustaining an ACL tear (P > .10). Likewise, no significant differences were observed between the intact versus rupture group in any of the quantified anatomic indices (P > .10). Similar findings were observed when the analyses were repeated on male and female skiers separately. CONCLUSION: Despite differences between sexes in knee anatomy and the injury risk, the sagittal and coronal slopes (LTS, MTS, CTS), as well as the concavity of the medial tibial plateau (MTD), were not associated with the risk of an ACL tear during a noncontact injury among recreational alpine skiers.

The effect of subacromial injections of autologous conditioned plasma versus cortisone for the treatment of symptomatic partial rotator cuff tears.

PURPOSE: Rotator cuff tears are one of the most common causes of shoulder malfunction and pain, which lead to a significant reduction in the quality of life. This present study investigated the effects of subacromial platelet-rich plasma injections [i.e. autologous conditioned plasma (ACP) injections] as compared to standard subacromial cortisone injection therapy in 50 patients with partial rotator cuff tears. METHODS: Before injection, and 6 weeks, 12 weeks and 6 months thereafter, the patients were assessed by the Constant-Murley score (CMS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the simple shoulder test (SST) and a pain visual analogue scale (VAS). An MRI was also performed before and 6 months after injection. RESULTS: Both patient groups had statistically significant better shoulder score outcomes over time. ASES, SST and CMS outcomes after 12 versus 6 weeks were better in the ACP group as compared to the cortisone group. VAS, ASES and CMS outcomes after 12 weeks versus baseline in the ACP group were better as compared to the cortisone group. There was a statistically significant difference between ACP group and cortisone group 12 weeks after injection regarding VAS, ASES, SST and CMS in favour of the ACP group. The MRI showed an improvement in grade of tendinopathy in both groups, however, without statistically significant differences between the two groups. CONCLUSION: Compared with cortisone injections, ACP injections show earlier benefit as compared to cortisone injections although a statistically significant difference after 6 months could not be found. Therefore, subacromial ACP injections are a good alternative to subacromial cortisone injections, especially in patients with contraindication to cortisone. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Percutaneous injections of Platelet rich plasma for treatment of intrasubstance meniscal lesions.

INTRODUCTION: management of intrasubstance meniscal lesions is still controversial. Intrasubstance meniscal lesions can lead to reduced sports activity and meniscal rupture. Physical therapy is often not satisfactory. Therefore new treatment methods are requested. Platelet Rich Plasma (PRP) has the ability to regenerate tissue; this was proved in several experimental studies. Whether percutaneous injections of PRP are effective in intrasubstance meniscal lesions is unknown. We hypothesize that percutaneous PRP injections lead to pain relief and halt of progression on MRI over 6 months in patients with grade 2 meniscal lesions. MATERIALS AND METHODS: ten recreational athletes with intrasubstance meniscal lesions (grade II according to Reicher) proven by MR-Imaging (MRI) were treated by percutaneous injections of PRP in the affected meniscal area. Three sequential injections in seven day intervals were performed in every patient. All injections were performed with image converter. Follow-up MRI was done six months after last injection in every patient. Level of sports activity and amount of pain at athletic loads according to numeric rating scale (NRS-11) were noted in each patient before injections and at the time of follow up MRI after six months. The t-test was used to determine statistical differences. RESULTS: four of ten patients (40%) showed decrease of meniscal lesion in follow up MRI after six months. Nine of ten patients (90%) complained about short episodes of heavy pain after the injections with average NRS-Score of 7.9 at daily loads after the last injection. Six of ten patients (60%) showed Improvement of NRS-Score at final follow up. Average NRS-Score improved significantly (p=0.027) from 6.9 before injections to 4.5 six month after treatment. Six of ten patients (60%) reported increase of sports activity compared to the situation before injections. In four patients (40%) additional surgical treatment was necessary because of persistent knee pain or progression of meniscal lesion. CONCLUSIONS: percutaneous injections of PRP have the ability to achieve pain relief and halt of progression on MRI over 6 months in patients with grade 2 meniscal lesions. Therefore it could be considered as a treatment option in patients with persisting pain. LEVEL OF EVIDENCE: IV.

Surgical technique for treatment of concomitant grade II MCL lesion in patients with ACL rupture.

Combined lesions of anterior cruciate ligament (ACL) and medial collateral ligament (MCL) are frequent in athletes. While surgical treatment of ACL injury is mandatory treatment regime of concomitant grade II MCL lesions remains unclear with tendency to surgical intervention. Standardized surgical technique is lacking. Present study wants to introduce surgical technique for treatment of concomitant grade II MCL lesion and report short term outcome results. 5 Patients with acute ACL rupture and grade II MCL-lesion were included. All patients received surgical treatment of concomitant MCL lesion by distinct surgical technique and ACL reconstruction. We evaluated valgus instability, anterior instability and range of motion (ROM) according to international knee documentation commitee (IKDC) and Lysholm­Score both preoperative and after 6, 16 weeks and 9 months postoperative. All Patients showed excellent clinical results at final follow-up. Valgus and anterior stability could be restored in all patients. 1 patient (20%) lost 15° in flexion of ROM at final follow up. However in all 5 patients (100%) the findings were graded as normal or nearly nor-mal according to IKDC knee examination form. Lysholm-Score averaged 94,6. Therefore presented surgical technique improved both, valgus and anterior stability, and led to excellent short term results at final follow up.

Clinical assessment is sufficient to allow outcome evaluation following surgical management of Achilles tendon ruptures.

STUDY DESIGN: cross-sectional study in otherwise healthy athletic adults with a unilateral Achilles tendon rupture. OBJECTIVES: define the relationships of active range of motion, calf circumference or number of heel raises to a full set of isokinetic parameters. BACKGROUND: Achilles tendon ruptures commonly occur during sports and create a considerable amount of morbidity. The benefits of different treatments are difficult to determine. Complex and expensive isokinetic testing is often required. If a simple force measurement could replace this testing, large clinical trials would be more easily feasible. METHODS: 74 patients with acute Achilles tendon rupture and surgical treatment were evaluated retrospectively. Active range of motion (ROM), ratio of ROM, number of heel raises, ratio of heel raises, calf circumference and isokintetic measurements were recorded. Regression using a Bayesian elastic net showed the most important correlations. RESULTS: Active range of motion showed a significant correlation to peak torque angle at flexion and extension as well as increased sports activity. There was a negative correlation to percutaneous therapy. Active Heel raise showed a positive correlation to peak torque at dorsal extension and increased sports activity as well as a negative correlation to high postoperative pain, where as calf circumference was positive correlated to peak torque at dorsal extension and body height as well as negative correlated to female gender. CONCLUSION: device independent measures, like range of Motion, and amount of Heel raise, are an excellent tool providing similar information compared to isokinetic testing and could be used to evaluate clinical outcome after Achilles tendon rupture.

Biologics for tendon repair.

Tendon injuries are common and present a clinical challenge to orthopedic surgery mainly because these injuries often respond poorly to treatment and require prolonged rehabilitation. Therapeutic options used to repair ruptured tendons have consisted of suture, autografts, allografts, and synthetic prostheses. To date, none of these alternatives has provided a successful long-term solution, and often the restored tendons do not recover their complete strength and functionality. Unfortunately, our understanding of tendon biology lags far behind that of other musculoskeletal tissues, thus impeding the development of new treatment options for tendon conditions. Hence, in this review, after introducing the clinical significance of tendon diseases and the present understanding of tendon biology, we describe and critically assess the current strategies for enhancing tendon repair by biological means. These consist mainly of applying growth factors, stem cells, natural biomaterials and genes, alone or in combination, to the site of tendon damage. A deeper understanding of how tendon tissue and cells operate, combined with practical applications of modern molecular and cellular tools could provide the long awaited breakthrough in designing effective tendon-specific therapeutics and overall improvement of tendon disease management.

Tendon healing: an overview of physiology, biology, and pathology of tendon healing and systematic review of state of the art in tendon bioengineering.

PURPOSE: Tendon injuries vary from acute rupture to chronic tendinopathy. For an optimal treatment of either condition, a profound knowledge is essential. Therefore, this article shall give an overview of physiology, biology, and pathology of tendon healing and state of the art in tendon bioengineering. METHODS: For a preferably comprehensive survey, the current literature listed in PubMed and published in English peer-reviewed journals (March 2013) was systematically reviewed for tendon healing and tendon bioengineering including cytokine modulation, autologous sources of growth factors, biomaterials, gene therapy, and cell-based therapy. No differentiation was made between clinical and preclinical in vitro investigations. RESULTS: Tendon healing happens in certain stadiums of inflammation, formation, and remodelling. An additional process of "collagen recycling" close to the healing site has been described recently. With increasing comprehension of physiology and pathology of tendon healing, several promising approaches in tendon bioengineering using growth factors, biomaterials, gene therapy, or cell-based therapy are described. However, only some of these are already used routinely in clinics. CONCLUSION: Strong and resistant tendons are crucial for a healthy musculoskeletal system. The new approaches in tendon bioengineering are promising to aid physiological tendon healing and thus resulting in a stronger and more resistant tendon after injury. The growing knowledge in this field will need to be further taken into clinical studies so that especially those patients with prolonged courses, revision surgery, or chronic tendinopathy and high-demanding patients, i.e., professional athletes would benefit. LEVEL OF EVIDENCE: II.

Frozen shoulder--comparison of different surgical treatment options.

In this study data from 54 patients with persisting primary frozen shoulder were collected and evaluated retrospectively. All included patients underwent a specific kind of surgical treatment of the shoulder. Three different surgical techniques were compared to each other. A group of 21 patients received a combination of arthroscopic capsular release and subacromial decompression. 18 patients were treated by subacromial decompression combined with mobilization under anesthesia and 15 patients underwent selective arthroscopic capsular release. We evaluated glenohumeral range of motion in every patient pre-and postoperatively. The investigated directions of motion were abduction, flexion and external rotation. The collected results were compared statistically. The mean follow-up of the treated patients was 37 weeks (range 11-52 weeks). All three surgical treatments improved the range of movement in every glenohumeral direction significantly. They achieved equal improvements in abduction and flexion. Regarding external rotation selective arthroscopic capsular release revealed not significantly better results than the other two surgical treatments, but there was a trend towards significance (p-value 0.0694). This study showed that all performed surgical techniques improved ranges of movement in the glenohumeral joint in patients with persistent frozen shoulder. Arthroscopic capsular release, alone or with subacromial decompression, is a safe procedure and showed the best results postoperatively. In our opinion arthroscopic capsular release should be recommended as the first choice treatment in persistent frozen shoulder.

Structural and biomechanical characteristics after early mobilization in an Achilles tendon rupture model: operative versus nonoperative treatment.

Acute Achilles tendon ruptures are common sports injuries; however, treatment remains a clinical challenge. Studies show a superior effect of early mobilization and full weight bearing on tendon healing and clinical outcome; however, few data exist on structural and biomechanical characteristics in the early healing phase. This study investigated the histological and biomechanical characteristics of early mobilization and full weight bearing in an Achilles tendon rupture model. Eighty rats underwent dissection of a hindpaw Achilles tendon; 40 rats were treated conservatively and 40 underwent open repair of the transected Achilles tendon by suturing. Early mobilization and full weight bearing were allowed in both groups. At 1, 2, 4, and 8 weeks after tenotomy, tensile strength, stiffness, thickness, tissue characteristics (histological analysis), and length were determined. Dissected Achilles tendons healed in all animals during full weight-bearing early mobilization. One and 2 weeks after tenotomy, rats in the operative group showed increased tensile strength and stiffness compared with the nonoperative group. Repair-site diameters were increased at 1, 2, and 8 weeks after tenotomy. Tendon length was decreased in the operative group throughout observation, whereas the nonoperative group showed increased structural characteristics on the cellular level and a more homogeneous collagen distribution. Surgical treatment of dissected rat Achilles tendons showed superior biomechanical characteristics within the first 2 weeks. Conservative treatment resulted in superior histological findings but significant lengthening of the tendon in the early healing phase (weeks 1-8).