A randomized controlled double-blind study of rotigotine on neuropsychiatric symptoms in de novo PD.

Management of apathy, depression and anxiety in Parkinson's disease (PD) represents a challenge. Dopamine agonists have been suggested to be effective. This multicenter, randomized (1:1), double-blind study assessed the 6-month effect of rotigotine versus placebo on apathy, depression and anxiety in de novo PD. The primary outcome was the change of apathy, measured with the LARS. The secondary outcomes were the change in depression and anxiety, measured with BDI-2 and STAI-trait and state. Forty-eight drug-naive PD patients were included. The primary outcome was not reached, with a surprisingly high placebo effect on apathy (60%). There was no significant difference in the change of depression at 6 months between rotigotine and placebo. Trait-anxiety was significantly improved by rotigotine compared to placebo (p = 0.04). Compared to placebo, low dose rotigotine significantly improved trait anxiety, but not apathy and depression. The major placebo effect on apathy points towards the importance of a multidisciplinary and tight follow-up in the management of neuropsychiatric symptoms.

Optimizing the deep brain stimulation care pathway in patients with Parkinson's disease.

Management of Parkinson's disease (PD) using deep brain stimulation (DBS) requires complex care in specialized, multidisciplinary centers. A well-organized, efficient patient flow is crucial to ensure that eligible patients can quickly access DBS. Delays or inefficiencies in patient care may impact a center's ability to meet demand, creating a capacity bottleneck. Analysis of the current practices within a center may help identify areas for improvement. After external audit of the DBS workflow of the Lyon Neurological Hospital and comparison with other European centers, manageable steps were suggested to restructure the care pathway. Propositions of the audit comprised, for example: (1) directly admitting referred patients to hospital, without a prior neurological outpatient visit and (2) including the preoperative anesthesia consultation in the hospital stay 1 month before surgery, not separately. This reorganization (between 2013 and 2016) was performed without increases in hospital medical resources or costs. The time from patients' first referral to surgery was reduced (from 22 to 16 months; p = 0.033), as was the number of pre- and postoperative patient visits (11-5; p = 0.025) and the total cumulative length of in-hospital stay (20.5-17.5 nights; p = 0.02). Ultimately, the total number of PD consultations increased (346-498 per year), as did the number of DBS implants per year (32-45 patients). In this single center experience, restructuring the DBS care pathway allowed a higher number of PD patients to benefit from DBS therapy, with a shorter waiting time and without decreasing the quality of care.

The natural course of shoulder instability and treatment trends: a systematic review.

BACKGROUND: The natural course of shoulder instability is still not entirely clear. We aimed in this review to analyse the current scientific evidence of the natural history of shoulder instability. MATERIALS AND METHODS: A systematic review of the English literature was performed using the PubMED database throughout January 2014. This review was guided, conducted and reported according to PRISMA criteria. The criteria for inclusion in the study were (1) the article was written in English, (2) the level of evidence was 1-4, (3) the article was available in full text, (4) the article investigated the natural history or course of shoulder instability, the outcome of non-operative management, or the regression of the shoulder symptoms to the mean. The methodological quality of each included study was individually assessed using a newly developed general assessment tool-Assessing the Methodological Quality of Published Papers (AMQPP). RESULTS: Eight articles related to shoulder instability met the inclusion criteria. Four papers were considered high-quality studies (evidence level 1 and 2). One paper assessed the natural history and the natural course of shoulder instability directly. The other studies indirectly assessed the natural history by studying non-operative and operative therapy trends. We found no articles which clearly referred to the role of 'regression to the mean'. CONCLUSION: Following the natural history and the implementation of standardised non-operative treatment programmes are an effective therapy and superior to surgery in many cases. However, primary acute shoulder dislocation in young active individuals partaking in demanding physical activities could benefit from early surgical intervention. The AMQPP score works as a quick quality-checking tool which helps researchers to identify the key points in each paper and reach a decision regarding the eligibility of the paper more easily. The AMQPP scoring system is still open for further development and expansion. Level of evidence Level IV.

[Rotator cuff repair: single- vs double-row. Clinical and biomechanical results]. / Rekonstruktion der Rotatorenmanschette: Single-row oder Double-row. Klinische und biomechanische Ergebnisse.

BACKGROUND: The goal of rotator cuff repair is a high initial mechanical stability as a requirement for adequate biological recovery of the tendon-to-bone complex. Notwithstanding the significant increase in publications concerning the topic of rotator cuff repair, there are still controversies regarding surgical technique. OBJECTIVES: The aim of this work is to present an overview of the recently published results of biomechanical and clinical studies on rotator cuff repair using single- and double-row techniques. MATERIALS AND METHODS: The review is based on a selective literature research of PubMed, Embase, and the Cochrane Database on the subject of the clinical and biomechanical results of single- and double-row repair. RESULTS: In general, neither the biomechanical nor the clinical evidence can recommend the use of a double-row concept for the treatment for every rotator cuff tear. Only tears of more than 3 cm seem to benefit from better results on both imaging and in clinical outcome studies compared with the use of single-row techniques. CONCLUSIONS: Despite a significant increase in publications on the surgical treatment of rotator cuff tears in recent years, the clinical results were not significantly improved in the literature so far. Unique information and algorithms, from which the optimal treatment of this entity can be derived, are still inadequate. Because of the cost-effectiveness and the currently vague evidence, the double-row techniques cannot be generally recommended for the repair of all rotator cuff tears.

Effect of single- and double-row rotator cuff repair at the tendon-to-bone interface: preliminary results using an in vivo sheep model.

INTRODUCTION: The clinical superiority of the double-row technique is still a subject of controversial debate in rotator cuff repair. We hypothesised that the expression of different collagen types will differ between double-row and single-row rotator cuff repair indicating a faster healing response by the double-row technique. MATERIALS AND METHODS: Twenty-four mature female sheep were randomly assembled to two different groups in which a surgically created acute infraspinatus tendon tear was fixed using either a modified single- or double-row repair technique. Shoulder joints from female sheep cadavers of identical age, bone maturity, and weight served as untreated control cluster. Expression of type I, II, and III collagen was observed in the tendon-to-bone junction along with recovering changes in the fibrocartilage zone after immunohistological tissue staining at 1, 2, 3, 6, 12, and 26 weeks postoperatively. RESULTS: Expression of type III collagen remained positive until 6 weeks after surgery in the double-row group, whereas it was detectable for 12 weeks in the single-row group. In both groups, type I collagen expression increased after 12 weeks. Type II collagen expression was increased after 12 weeks in the double-row versus single-row group. Clusters of chondrocytes were only visible between week 6 and 12 in the double-row group. CONCLUSIONS: The study demonstrates differences regarding the expression of type I and type III collagen in the tendon-to-bone junction following double-row rotator cuff repair compared to single-row repair. The healing response in this acute repair model is faster in the double-row group during the investigated healing period.

[The effect of arthroscopic debridement and conservative treatment in knee osteoarthritis: Results of a 5-year follow-up and literature review]. / Die Behandlung moderater Kniegelenksarthrosen durch arthroskopisches Gelenkdebridement: 5-Jahres-Ergebnisse und systematisches Review.

PURPOSE: This study is aimed to compare the effects of arthroscopic joint debridement over a 5-year period in a clearly defined patient population (only grade III knee osteoarthritis, history < 2 years). MATERIAL AND METHODS: A total of 96 patients (50 male and 46 female) underwent arthroscopic knee debridement for knee OA. The main criteria for inclusion were osteoarthritis grade III (Kellgren-Lawrence score) and a maximal history of 2 years. RESULTS: The subjective complaints and the knee-related quality of life were estimated by the KOOS (knee injury and osteoarthritis outcome score). The score increased significantly within the 1 to 3 rd year post operation. After this interval the mean points of the score declined. But after 5 years the KOOS was higher in comparison to the baseline dates. Patients who had undergone conservative treatment at baseline had a significantly different KOOS than patients in the arthroscopy group. Over time, patients in the arthroscopy group had fewer complaints than patients in the conservative treatment group. In both groups, the results decreased over time. A total of 17 patients (17.2 %) needed a conversion to total endoprothetic replacement. The mean time-interval between index operation and conversion was 56.6 (95 % CI 54.4 - 58.4) months. CONCLUSIONS: In middle stages of knee OA, arthroscopic joint debridement can effectively reduce subjective complaints. Because this treatment does not stop the process of OA, the improvements decrease over time.

Mechanical testing of different knot types using high-performance suture material.

PURPOSE: This laboratory study aimed to evaluate the loop security, knot security, cyclic loading resistance and load-to-failure rate of three different knot types with establishing a new experimental set-up. Additionally, the mode of failure of each knot was evaluated. METHODS: With the use of nonabsorbable, braided polyethylene sutures, USP size No. 2 [Hi-Fi®; ConMed Linvatec], the arthroscopic knot types Dines, SMC as well as the surgeon's knot were tested using a material testing machine. The knots were tied openly as well as arthroscopically. The set-up enables testing of knot configurations while eliminating friction between knot loop and its suspension points. Including all test procedures, a total of 216 knots were tested. RESULTS: All openly tied knot types and ten of each type of arthroscopically tied knots resisted against cyclic loading of 1,000 cycles. With subsequent load-to-failure testing, openly tied knot types achieved significantly higher values of tensile strength than arthroscopically tied knots. Regarding clinical failure, defined as an elongation of 3 mm, Dines knot reached highest loop as well as knot security. Knot slippage was the most common failure mechanism at an elongation of 3 mm, whereas suture breakage was evaluated most at an elongation of 6 mm. CONCLUSIONS: The new experimental set-up confirms the loop security of arthroscopic knot types. Using a knot pusher clinically is a key factor to attain this as compared to openly hand-tied techniques. The Dines knot presented the highest reliability. It may provide a secure tissue healing during rehabilitation and consequently can be recommended for clinical application.

[Evaluation of cartilage degeneration by near infrared spectroscopy (NIRS): methodical description and systematic literature review]. / Bestimmung des Degenerationsgrads am hyalinen Gelenkknorpel durch Nah-Infrarot-Spektroskopie (NIRS): Methodenbeschreibung und Literaturübersicht.

Damage to hyaline cartilage is the most important pathophysiological tool in the development of osteoarthritis. Cartilage lesions are the most frequent pathological findings during arthroscopic operations. Arthroscopies as well as magnetic resonance tomography are gold standards for detection of cartilage lesions. But the arthroscopic evaluation of cartilage lesions is descriptive and subjective only. The surgeon is able to differentiate between intact cartilage surface, softening, superficial or deep fissure or flake and finally a complete defect. In routine arthroscopy the grading mostly is made by use of different scores [e.g. ICRS (International Cartilage Repair Society), Outerbridge, Insall, Jäger-Wirth or others]. Because the arthroscopic evaluation is subjective the reliability of this method is poor. Spectroscopic methods are established for evaluation of different tissue diseases in different indications. NIRS (near infrared spectroscopy) has become an important method for medical diagnostics in the last years. NIR is very energy-rich and suitable for glass fibre transport without relevant reduction. Insofar this technology may be ideal for endoscopic procedures. Our systematic literature review reveals that NIRS is a sufficient method for an objective diagnosis of cartilage lesions. In the current work we demonstrate an NIRS-based device for intraoperative, real-time cartilage evaluation. Furthermore, we discuss the possible clinical consequences from such measurements.

[Cartilage regeneration after high tibial osteotomy. Results of an arthroscopic study]. / Knorpelregeneration nach valgisierender Tibiakopfosteotomie. Ergebnisse einer arthroskopischen Studie.

AIM: High tibial osteotomy (HTO) has been established as an effective method for the treatment of unicondylar knee osteoarthritis. This study was undertaken to quantify the potential for restoration of cartilage lesions or defects after HTO in relation to different cartilage treatment modalities. Control arthroscopy was undertaken to identify the cartilage lesions within the knee joint 1.5 years after medial opening wedge osteotomy. MATERIAL AND METHOD: A total of 135 patients (72 male and 63 female) had undergone medial-opening high tibial osteotomy and arthroscopy. The mean age at operation was 48.8 (36 to 65) years. All HTO were fixed with an angle-stable, mobile spacer-containing plate (HTO-Platte, Königsee, Deutschland). All HTO were combined with a simultaneous arthroscopy. Grade III cartilage lesions had undergone either shaving or temperature-controlled chondroplasty (Paragon ArthroW Austin, TX, USA). In some case these cartilage lesions had remained untreated. Control arthroscopy and removal of the implants was performed 1.5 years after HTO. The cartilage lesions were graded accordingly to the ICRS guidelines (International Cartilage Repair Society). RESULTS: The KOOS at HTO was 49.9 (SD 10.6) points. We observed at follow-up a mean increase from 66.1 (SD 28.8, 95 % CI: 61.2-71.1) points. The KOOS at follow-up was 16.1 (SD 29.8) points. There was no delayed union of the HTO space. Before HTO the varus angle was 10.4° (SD 3.9 range 5 to 20°). The correction angle was 13.6° (SD 4.4, 95 % CI: 12.9-14.4°). Finally we determined a valgus angle of -3.2° (SD 1.8 minimum 0° varus, maximum -6° valgus. The clinical outcome (KOOS) significantly (p < 0.001) correlated (R = 0.605) with the extension of valgisation. Patients with a valgus angle of 3° and more had the best outcome. Of the grade III lesions 40.4 % in the medial femoral condyle and 62.3 % in the medial tibial plateau increased to grade II or I lesions. In 13.1 % of the medial femoral condyle and 8.5 % of medial tibial plateau cases we found complete (grade IV) defects at control arthroscopy. The highest rate of regenerations was detected after temperature-controlled chondroplasty. The worst results were produced after mechanical debridement. Microfracturing of complete defects produced regeneration in about ⅔ in the medial femoral condyle and about ⅓ in the medial tibial plateau. No increase was observed within the lateral or patello-femoral compartment. No correlation was seen between cartilage regeneration and outcome. The extension of valgisation did not influence the cartilage regeneration. CONCLUSIONS: The main effect of the HTO is the shift of the weight-bearing line from the arthritic compartment to the opposite femorotibial healthy one. In addition, HTO also produces a partial restoration of cartilage lesions. Deep cartilage lesions (grade III) restore in about 60 % of the cases after HTO. The worst restoration is found after mechanical shaving. This method should be avoided in the future. The best restoration was found in deep lesions after thermochondroplasty. Furthermore, in about half of the patients with complete (grade IV) defects, microfracturing caused the formation of fibrocartilaginous regenerates. This procedure should always be performed if possible.

[Visualisation of bioabsorbable suture anchors with digital projection radiography and magnetic resonance imaging]. / Visualisierung bioresorbierbarer Fadenanker-Implantate mit digitaler Projektionsradiografie und Magnetresonanztomografie.

BACKGROUND: During the last few years bioabsorbable suture anchors have become widely established along side metallic suture anchors in orthopaedic surgery. However, there are still some difficulties in evaluating the postoperative situation after implanting bioabsorbable suture anchors. The aim of this study was to examine the visualisation of bioabsorbable suture anchors with digital projection radiography and magnetic resonance imaging. MATERIALS AND METHODS: Ten Mitek-Anchor-Panalok® suture anchors made of polylactic acid were implanted in an ex-vivo animal study design. After implantation the specimens were examined with digital projection radiography and MRI. The analysis was performed with regard to the bony defects and the anchor material itself. RESULTS: With digital projection radiography and MRI, it was possible to detect the bony defects after implantation of the anchors. The anchor material could not be visualised. CONCLUSION: The results of this study demonstrate that neither digital projection radiography nor MRI is well suited for the detection of the bioabsorbable suture anchors in the postoperative situation. Whereas the bony defects can be well described, the anchors cannot be directly visualised. The visualisation of bioabsorbable anchors remains a clinical problem in orthopaedic surgery.

[Treatment of locked chronic posterior dislocation of the shoulder]. / Therapie der verhakten chronischen hinteren Schulterluxation.

INTRODUCTION: The posterior locked shoulder dislocation is a rare injury that is often associated with an impression fracture of the anteromedial aspect of the humeral head. The majority of posterior shoulder dislocations are missed on the initial examination. METHODS: We demonstrate the case of an athlete, who presented with a posterior shoulder dislocation after a trauma two months ago. RESULTS: The patient was treated with a M. subscapularis transfer in the reverse-hill-sachs-lesion. DISCUSSION: The diagnosis of the posterior shoulder dislocation remains a problem in the clinical setting. Treatment is based on the size defect of the anteromedial humeral head. Different treatment options are still controversially discussed. CONCLUSION: To diagnose a posterior shoulder dislocation correctly a standard clinical and radiological assessment is necessary.

[The prevalence of radiological osteoarthritis in relation to age, gender, birth-year cohort, and ethnic origins]. / Die Prävalenz der radiologischen Gonarthrose in Bezug zu Lebensalter, Geschlecht, Jahrgangskohorte und ethnischer Zugehörigkeit. Eine Metaanalyse.

AIM: This metaanalysis was performed to evaluate the prevalence of the radiological assessed knee osteoarthritis in the whole community. MATERIALS AND METHODS: Medical databases (Medline, EMBASE, Cochrane) were searched for the strategy: ["Osteoarthritis" and "Knee" and "Prevalence"]. The deadline for the search was 31.12.2009. Two investigators (first and senior author) independently made the selection from 17 studies (from a total of 1428) according to the inclusion criteria: a cross-sectional study of the whole community, radiological investigation and definition of knee ROA by an established radiological score. Only studies in English or German language were evaluated. Effect sizes (event rate, odds ratio [OR] and confidence interval [CI]) were calculated by the software "Comprehensive Metaanalysis V2". Study heterogeneity (I2) was determined accordingly to Higgins. RESULTS: The kappa index for interobserver validity was k = 0.948. All studies judged the grade of osteoarthritis according to the Kellgren-Lawrence (KL) score. For calculation of knee ROA KL grades 2+ were estimated only. The total prevalence of knee ROA was 24.3 % (CI 23.4-25.2 %). The whole prevalence in male patients was 24.3 % (CI 23.4-25.2 %); I2 = 59.4 (p = 0.002) and in female patients 32.6 % (CI 31.8-33.4 %); I2 = 49,1 (p < 0.001). Younger male patients (age 50-) had a prevalence of 5.6 (CI 4.5-6.8). In older patients (80+) the male prevalence was 44.5 % (CI 39.6-49.5 %). In this age group female patients had a prevalence of 71.6 % (CI 67.6-75.3 %). The higher prevalence of knee ROA in female patients was significant (OR = 1.8 [1.7-1.9]; I2 = 46.0 [p < 0.001]). The prevalence of knee ROA was higher in male Asians compared with male Caucasians (OR = 1.1, CI 0.9-1.2; p = 0.080) in tendency. This difference was significant in female patients (OR = 2.2; CI 2.0-2.4; p < 0.001). Furthermore another trend was evaluated. Female patients (70-79 years) from the birth-year cohort 1920- had a prevalence of 37.8 % (CI 35.9-39.7)%. In contrast female patients from the birth-year cohort 1920 had a prevalence of 62.8 % (CI 60.8-64.8 %) at 70-79 years. This difference was significant (OR = 2.8; CI 2.5-3.1; p < 0.001). CONCLUSIONS: This investigation confirms the high prevalence of knee ROA. The evaluated data may serve as a reference for medical or scientific investigations in the future.

[The modular endoprosthetic system Munich-Luebeck (MML): potential applications and results in the lower extremities]. / Modulares Endoprothesensystem München-Lübeck (MML) : Anwendungsmöglichkeiten und Ergebnisse an den unteren Extremitäten.

The modular endoprosthetic system Munich-Luebeck (MML) has been in clinical use since 1994. A total of 2.118 pelvic and lower extremity surgeries using the MML system were carried out up until 2010. The modular construction allows substituting or bridging any kind of bone defect. We analyzed 572 operative interventions, which were performed in 5 centers. The most frequent indications were tumors (50.3%) followed by revision arthroplasty due to loosening, periprosthetic fractures, and joint resection surgery due to infection (43.3%). Proximal and distal femoral replacement amounted to 78% of cases, whereas partial pelvic replacement accounted for 10.4% of the cases. Complications were reported in 27.27% of the cases, where dislocations (14.9% of the cases with simultaneous hip replacement) and infections (10.48%) were the most common, as expected. Revision surgery was necessary in 140 (24.8%) of the 572 patients, of which 68 were partial or total replacement of the implants, 16 removal of the implants and 10 above-knee amputations or rather exarticulations of the hip.

[Behavioral disorders in Parkinson's disease: from pathophysiology to the mastery of dopaminergic treatment]. / Maladie de Parkinson: de la physiopathologie des troubles psychiques à la maîtrise du traitement dopaminergique.

INTRODUCTION: Behavioral changes in Parkinson's disease are complex and their pathophysiology is not yet fully understood. The dopaminergic system seems to play a major role and most of the behavioral disorders in Parkinson's disease can be classified into either hypodopaminergic if related to the disease itself or hyperdopaminergic if related to dopaminergic treatment. STATE OF THE ART: Subthalamic stimulation, which enables withdrawal of dopaminergic medication at an advanced stage in the disease, provides a model for the study of certain nonmotor, dopamine-sensitive symptoms. Such a study has shown that apathy, which is the most frequent behavioral problem in Parkinson's disease, is part of a much broader hypodopaminergic behavioral syndrome which also includes anxiety and depression. Nonmotor fluctuations--essential fluctuations in the patient's psychological state--are an expression of mesolimbic denervation, as shown in positron emission tomography. Drug-induced sensitization of the denervated mesolimbic system accounts for hyperdopaminergic behavioral problems that encompass impulse control disorders that can be alternatively classified as behavioral addictions. The association of impulse control disorders and addiction to the dopaminergic medication has been called dopamine dysregulation syndrome. While L-dopa is the most effective treatment for motor symptoms, dopamine agonists are more effective in improving the nonmotor levodopa-sensitive symptoms. On the other hand, L-dopa induces more motor complications and dopamine agonist more behavioral side effects. There is increasing data and awareness that patients' quality of life appears to be dictated by hypo- and hyperdopaminergic psychological symptoms stemming from mesolimbic denervation and dopaminergic treatment rather than by motor symptoms and motor complications related to nigrostriatal denervation and dopaminergic treatment. PERSPECTIVES: Better management requires knowledge of the clinical syndromes of hyper- and hypodopaminergic behaviors and nonmotor fluctuations, a better understanding of their underlying mechanisms and the development of new evaluation tools for these nonmotor symptoms. CONCLUSIONS: The neurologist who strives to gain mastery of dopaminergic treatment needs to fine tune the dosage of levodopa and dopamine agonists on an individual basis, depending on the presence of motor and nonmotor signs respectively.

Intraosseous foreign body granuloma in rotator cuff repair with bioabsorbable suture anchor.

Biodegradable implants lead to problems such as cyst formation, soft-tissue inflammation, loose implant fragments or local osteolysis. This report represents the first published case of an intraosseous foreign body granuloma in the humeral head after arthroscopic rotator cuff tear fixation with a poly-L: -lactide (PLLA) suture anchor. A 48-year-old female patient presented with pain in her right shoulder. A refixation of her right supraspinatus tendon with a biodegradable suture anchor was performed 11 months ago at an external hospital. Laboratory tests showed normal values for C-reactive protein, leukocytes and the erythrocyte sedimentation rate. No signs of infection or instability were noted. The visual analogue scale (VAS) was 8, the simple shoulder test (SST) was 4 and the American shoulder and elbow surgeons score (ASES) was 44. Plain radiographs showed high lucency in the area of the tuberculum majus. MRI showed an intra- and extraosseous mass surrounded by fluid in this area. Surgical care involved arthroscopic debridement and removal of the suture anchor. Histological examination revealed a foreign body granuloma. At the 18-month follow-up the patient was nearly pain-free. The VAS was 2, SST was 10 and ASES was 88. Foreign body granulomas are a well known but rarely described complication that arises after the use of biodegradable suture anchors in shoulder surgery. Every patient presenting with shoulder pain after usage of a biodegradable fixation material should be evaluated closely. Orthopaedic surgeons should be aware of the possibility of delayed foreign body reactions, especially after using PLLA anchors.

Initial load-to-failure and failure analysis in single- and double-row repair techniques for rotator cuff repair.

AIM: This experimental study aimed to compare the load-to-failure rate and stiffness of single- versus double-row suture techniques for repairing rotator cuff lesions using two different suture materials. Additionally, the mode of failure of each repair was evaluated. METHOD: In 32 sheep shoulders, a standardized tear of the infraspinatus tendon was created. Then, n = 8 specimen were randomized to four repair methods: (1) Double-row Anchor Ethibond coupled with polyester sutures, USP No. 2; (2) Double-Row Anchor HiFi with polyblend polyethylene sutures, USP No. 2; (3) Single-Row Anchor Ethibond coupled with braided polyester sutures, USP No. 2; and (4) Single-Row Anchor HiFi with braided polyblend polyethylene sutures, USP No. 2. Arthroscopic Mason-Allen stitches were placed (single-row) and combined with medial horizontal mattress stitches (double-row). All specimens were loaded to failure at a constant displacement rate on a material testing machine. RESULTS: Group 4 showed lowest load-to-failure result with 155.7 +/- 31.1 N compared to group 1 (293.4 +/- 16.1 N) and group 2 (397.7 +/- 7.4 N) (P < 0.001). Stiffness was highest in group 2 (162 +/- 7.3 N/mm) and lowest in group 4 (84.4 +/- 19.9 mm) (P < 0.001). In group 4, the main cause of failure was due to the suture cutting through the tendon (n = 6), a failure case observed in only n = 1 specimen in group 2 (P < 0.001). CONCLUSIONS: A double-row technique combined with arthroscopic Mason-Allen/horizontal mattress stitches provides high initial failure strength and may minimize the risk of the polyethylene sutures cutting through the tendon in rotator cuff repair when a single load force is used.

How valid is the arthroscopic diagnosis of cartilage lesions? Results of an opinion survey among highly experienced arthroscopic surgeons.

AIM: In general, arthroscopy is considered the "gold standard" for the evaluation of cartilage lesions. In this multicenter survey, we ascertained the general opinion of surgeons regarding arthroscopic cartilage diagnoses. METHOD: A total of 301 highly experienced arthroscopists (instructors of the AGA, the German-speaking society of arthroscopy) were contacted in writing with a request to complete the survey. RESULTS: The data from 105 respondents (34.8% of those contacted) were used for the investigation. In the grading of the cartilage lesions, the Outerbridge classification was most frequently used (n = 87), followed by the ICRS protocol (n = 8) and the Insall score (n = 3). The majority (61%) of the arthroscopic surgeons felt that differentiation between healthy cartilage and low-grade cartilage lesions was simple. For differentiation between grade I and grade II lesions, and for differentiation between grade II and grade III lesions, 41.9 and 51.4%, respectively, thought that there was a "need for improvement". In the case of grade IV lesions, 70.5% of the surgeons thought that the diagnosis was valid. The respondents also judged the utility of incorporating objective measurements (e.g., intraoperative biomechanical tests): 13.3% (n = 14) responded that such measurements would be "very useful" and 61.9% (n = 65) responded that they would be "somewhat useful". CONCLUSIONS: Among surgeons, arthroscopy was not perceived to be as reliable as a "gold standard" for the diagnosis of cartilage lesions. The majority of experienced arthroscopists felt unsure of the results in general, or at least in some cases. A universal and definitive grading system for lesions appears to be needed. For questionable cases, measurement devices are needed for objective cartilage grading.

Arthroscopic evaluation of the ACL double bundle structure.

In order to describe the arthroscopic presence of the double bundle structure and to evaluate the value of different portals in knee arthroscopy, we assessed the AM and PL bundle anatomy. We prospectively examined the knees of 60 patients undergoing arthroscopic surgery for pathology unrelated to the ACL. Arthroscopy was performed in a two portal technique using an anterolateral (ALP) and an anteromedial (AMP) portal. With the arthroscope in the ALP, we could distinguish an AM and PL bundle in 28%. Switching the arthroscope to the AMP, differentiation of the bundles was possible in 67%. In all remaining cases visualization of the PL bundle was possible after retraction of the AM bundle. Use of AMP increased visualization of the PL bundle. It seems reasonable to perform arthroscopy for ACL reconstruction with the arthroscope in the AMP and to establish an additional medial working portal to increase the visualization of the femoral ACL insertion sites for optimal femoral tunnel placement.