Increase in cartilage degeneration in all knee compartments after failed ACL reconstruction at 4 years of follow-up.

PURPOSE: Degeneration of the cartilage after anterior cruciate ligament reconstruction (ACL-R) is known, and further deterioration can be expected in patients with tunnel malplacement or partial meniscal resection. It was hypothesized that there is a significant increase in cartilage degeneration after failed ACL-R. MATERIAL AND METHODS: Isolated ACL revision surgery was performed in 154 patients at an interval of 46 ± 33 months (5-175 months) between primary and revision surgery. Cartilage status at the medial, lateral femorotibial, and patellofemoral compartments were assessed arthroscopically during primary and revision ACL-R in accordance with the Outerbridge classification. Tunnel placement, roof angle, and tibial slope was measured using anteroposterior and lateral radiographic views. RESULTS: Cartilage degeneration increased significantly in the medial femorotibial compartment, followed by the lateral and patellofemoral compartments. There was a correlation between both cartilage degeneration in the patellofemoral compartment (PFC) (rs = 0.28, p = 0.0012) and medial tibial plateau (Rs = 0.24, p = 0.003) in relation to the position of tibial tunnel in the frontal plane. Worsening of the cartilage status in the medial femorotibial compartment, either femoral or tibial, was correlated with the tibial aperture site in the lateral view (Rs = 0.28, p < 0.001). Cartilage degeneration in the lateral compartment of the knee, on both femoral or tibial side, was inversely correlated with the femoral roof angle (Rs = -0.1985, p = 0.02). Meniscal tears, either at the medial or lateral site or at both, were found in 93 patients (60%) during primary ACL-R and increased to 132 patients (86%) during revision ACL-R. DISCUSSION: Accelerated cartilage degeneration and high prevalence of meniscal lesions are seen in failed ACL-R. Tunnel placement showed significant impact on cartilage degeneration and may partially explain the increased risk of an inferior outcome when revision surgery is required after failed primary ACL-R. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Joint effusion, anteroposterior stability, muscle strength and degree of patellofemoral osteoarthritis significantly impact outcome following revision ACL reconstruction.

PURPOSE: Effusion, impaired muscle function and knee instability are considered as some of the most important factors effecting outcome following anterior cruciate ligament reconstruction (ACL-R) but the impact on revision ACL-R remains unclear. It was hypothesized that these factors will significantly worsen clinical outcome following revision ACL-R. METHODS: Seventy knees (13 female and 57 male) were followed retrospectively after revision ACL-R at a mean follow-up of 47.8 ± 20.7 months. Clinical examination was based on the International Knee Documentation Evaluation Form-2000 (IKDC), Tegner activity scale. Instrumented measurement of anterior tibial translation was performed using the Rolimeter® (DJO Global, Freiburg, Germany). Bilateral circumference of the thigh was measured 10 and 20 cm proximal to the medial joint space. Cartilage was assessed according to Outerbridge classification during both primary and revision ACL-R. RESULTS: Tegner activity scale decreased significantly from 7.8 ± 1.4 points at primary ACL-R to 7 ± 1.8 points at revision ACL-R, and 5.8 ± 1.7 points at the time of follow up (p < 0.001). Joint effusion (r = - 0.47, p < 0.01) and side to side differences in single leg hop test (r = - 0.48, p < 0.1) significantly correlated with inferior outcome. Cartilage lesions were found in 67% of the patients at the time of revision ACL-R compared to 38% at the time of primary ACL-R. According to the IKDC classification A was graded in three patients (4.3%), B in 35 (50%), C in 29 (41.4%) and D in three (4.3%). Joint effusion was measured in 35% of patients at the time of follow-up. Degeneration at the patellofemoral compartment of > grad 2 was responsible for IKDC grade C and D (p = 0.035). Instrumented anteroposterior site-to-site difference of ≥3 mm showed significant impact on clinical outcome (p < 0.019). CONCLUSION: The study has shown that chronic effusion, quadriceps dysfunction, cartilage lesions especially at the patellofemoral compartment and side to side difference in anteroposterior stability significantly influences patient outcome after revision ACL-R. These factors require special attention when predicting patient's outcome. LEVEL OF EVIDENCE: Level-IV, case-controlled study.

Indication, Technique and Long-term Results after Shoulder Arthrodesis Performed with Plate Fixation.

AIM: Arthrodesis of the shoulder joint is a radical event, so it is difficult to explain its significance to patients. It has been the last resort in hopeless cases. Knowledge of long-term results and evaluation of advantages and disadvantages seems to be helpful in this regard. METHODS: Eleven patients with mean age of 45 (31 - 58) years were operated between 2000 and 2013. All patients could be included in the investigation (FU mean 8.5 [3 - 16] years; 8 male and 3 female; right 9, left 2). Patients had the following indications: persistent instability 5 (2 with epilepsy), rotator cuff rupture 2 (1× after combined latissimus dorsi and teres major transfer), brachial plexus injury/defect 2, locked dislocation 1 and posttraumatic arthropathy 1. Fixation with DC plate (pre-bent to 110°) was used in all cases; with special focus on placing at least one screw in the scapular neck. The targeted arthrodesis position was abduction 30°, forward flexion 30°, and internal rotation 30°. RESULTS: Active abduction improved from 12 to 63°, forward flexion from 21 to 79° and internal rotation from 10 to 47° (mean values). In the resting position with hanging arm aside, mean abduction was 3° and forward flexion 8°. Nine of 11 patients had considerable relief of pain, from 8.3 to 2.4 points VAS. Five patients rated the outcome as excellent, 3 as good and 1 as satisfactory. Nine patients would repeat the procedure. In summary, an Oxford Shoulder Score of 31.6 points was achieved, and SSV of 58%. Bony fusion was achieved in all cases, 3 - 4 months p. o. in mean. There were no important neurological or angiological complications. CONCLUSIONS: Plate arthrodesis in the technique used achieves high fusion and a low complication rate. Relief of pain and functional improvement are astonishing. Analysis of our results indicates that correction of the positions mentioned above is necessary: i. o. arthrodesis position for abduction 25° (by means of pre-bending plate of 105°), forward flexion 20° and internal rotation 30° are suggested.

Relationship between the Handball-Specific Complex-Test and Intermittent Field Test performance in professional players.

BACKGROUND: We investigated the relationship between the Handball Complex-Test (HBCT) and two selected field performance tests (the repeated sprint ability [RSA], and the Yo-Yo Intermittent Recovery Test) in elite handball players. METHODS: Nineteen handball players (age: 25.7±5.1 years) were drawn from the First Professional German League. The HBCT consists of four activity series (AS): agility parcours, defensive action, sprint (10 m, 20 m) and throw-on-goal parcours; these activities were completed twice, with five active pauses of 30-35 s, and a follow-up of recovery over the subsequent 10 minutes. The RSA comprised 6 x (15+15 m) sprints starting every 20 s; scoring noted best time (RSAbest), total time (RSATT) and decrement (RSAdec). In the Yo-Yo Intermittent Recover, we recorded the total distance covered (TD). Heart rates (HR) were recorded throughout and recovery was assessed for measurements immediately post-test (R0) and 10 minutes after completing the test (R10). RESULTS: A strong correlation was found between HBCT and fastest 10 m and 20 m RSA sprint times (r=0.811, r=0.815, respectively). Also, the HBCT total 10 m and 20 m sprint times showed a strong positive association with RSATT (r=0.70; r=0.63, respectively), and the RSA heart rate post-test was strongly correlated with the HBCT heart rate after round two (r=0.865). CONCLUSIONS: Data from the match-specific HBCT Test shows a strong positive association with other more generic intermittent field test measurements. These observations support the validity of using the generic tests to monitor current fitness and responses to training in team handball players.

Relationships between the handball-specific complex test, non-specific field tests and the match performance score in elite professional handball players.

BACKGROUND: This study assessed the validity of the handball-specific complex test (HBCT) and two non-specific field tests in professional elite handball athletes, using the match performance score (MPS) as the gold standard of performance. METHODS: Thirteen elite male handball players (age: 27.4±4.8 years; premier German league) performed the HBCT, the Yo-Yo Intermittent Recovery (YYIR) test and a repeated shuttle sprint ability (RSA) test at the beginning of pre-season training. The RSA results were evaluated in terms of best time, total time, and fatigue decrement. Heart rates (HR) were assessed at selected times throughout all tests; the recovery HR was measured immediately post-test and 10 minutes later. The match performance score was based on various handball specific parameters (e.g., field goals, assists, steals, blocks, and technical mistakes) as seen during all matches of the immediately subsequent season (2015/2016). RESULTS: The parameters of run 1, run 2, and HR recovery at minutes 6 and 10 of the RSA test all showed a variance of more than 10% (range: 11-15%). However, the variance of scores for the YYIR test was much smaller (range: 1-7%). The resting HR (r2=0.18), HR recovery at minute 10 (r2=0.10), lactate concentration at rest (r2=0.17), recovery of heart rate from 0 to 10 minutes (r2=0.15), and velocity of second throw at first trial (r2=0.37) were the most valid HBCT parameters. CONCLUSIONS: Much effort is necessary to assess MPS and to develop valid tests. Speed and the rate of functional recovery seem the best predictors of competitive performance for elite handball players.

Patella Dislocation in Children and Adolescents.

Introduction Patellar dislocation is one of the commonest knee injuries in adolescents. Although treatment usually leads to good results, the influence of anatomical and functional factors on therapeutic strategy has been underestimated, especially in cases of recurrence. Patients and Methods The course of treatment has been analysed in 88 patients with 136 patellar dislocations. The importance of anatomical conditions was studied using X-ray and MRI findings. The treatment results were critically evaluated in comparison with current recommendations. Results From 2000 to 2015, 109 patellar dislocations occurred in 88 patients; a further 27 previous dislocations were reported by the patients (mean age 14 years, 47 boys and 41 girls). About one-third of patients (35.2 %) suffered one or more recurrences. Almost half (48.6 %) of the dislocations occurred during physical exercise, particularly ball sports. Osteochondral flake fracture was found in 9 % of the patients, and a lesion of the medial patellofemoral ligament in 96 %. There was an anatomical predisposition to patellar dislocation in almost all cases. The sulcus angle, patellar and trochlear dysplasia, and patellar height were highly significantly different between the patient group and controls. The TT-TG distance was subsequently calculated, but had no impact on therapy. Seventy-seven patients were treated conservatively and 32 patients surgically. The conservative procedure included partial immobilisation for six weeks. Surgical reconstruction or tightening was performed in 27 cases; in five, in combination with other surgical procedures. Plasty of the medial patellofemoral ligament with a tendon graft was performed in five patients, and osteochondral or meniscal lesions were repaired in 10 patients. Recurrences occurred in 41.7 % of conservatively treated knees and in 29.6 % of surgically treated knees (without reconstruction with a tendon graft). No recurrence was seen after reconstruction of the medial patellofemoral ligament with a tendon graft. Fifty-four patients underwent a follow-up examination. Fourteen of these (25.9 %) had suffered a recurrence. The outcome 16 months after the end of treatment was mostly good, as were the results of self-assessment (Larson-Lauridsen Score). Conclusion An anatomical predisposition is detectable in almost all cases of patellar dislocation, but frequently occurs with an accident event, e.g. in ball sports. Primary patellar dislocations without serious concomitant injuries may be treated conservatively. In the event of recurrence, the indication for surgery is given, even in young patients and in any patient with an osteochondral flake fracture. Tightening reconstruction of the MPFL used to be frequently performed, but is associated with a high rate of recurrence.

Differences in anthropometric characteristics in relation to throwing velocity and competitive level in professional male team handball: a tool for talent profiling.

BACKGROUND: The primary aim of the study was to examine the anthropometric characteristics as well as throwing and sprinting performance of professional handball players classified by playing position and competition level. METHODS: 21 male players (age: 25.2±5.1 years) from the first German handball league (FGL) and 34 male players (age: 26.1±4.1 years) from the third German handball league (TGL) were categorized as backs, pivots, wings and goalkeepers. Measurements included anthropometric data (height, mass and body mass index (BMI)), throwing and sprinting performance selected out of a complex handball test (HBCT), which was conducted twice (2 rounds). During the HBCT, the subjects performed two sprints (10, 20 m), two standing throws with run-up (ST) and four vertical jump throws (VJT) over a hurdle (20 cm) with and without precision for goal shot. RESULTS: The anthropometric data revealed a significantly (P=0.038 and η2=0.079) shorter body height for TGL than for FGL players. In the cohort of first league athletes the pivots were the tallest (1.98±0.04 m), backs in the third league showed the maximum body height (1.90±0.05 m). Regarding body mass, pivots were the heaviest players independent from the league membership. The FGL players showed a significantly (P<0.05 and η2>0.10) higher throwing velocity in all type of throws. Body height was significantly related to ST (r=0.53) and VJT (r=0.52) in the first round of HBCT but only for the FGL athletes. Throwing velocity was also correlated with BMI (r=-0.50) among the TGL players. CONCLUSIONS: Substantial differences of body characteristics, throwing and sprinting performance between playing positions and competitive levels underline the importance of a careful scouting and position-specific training for professional handball players.

Anthropometric and physical performance characteristics of professional handball players: influence of playing position.

BACKGROUND: The aims of the study were to examine the anthropometric and physical performance characteristics of professional handball players classified by playing position. METHODS: Twenty-one competitors (age: 25.2±5.1 years) were categorized as backs, pivots, wings or goalkeepers. Measures included anthropometrics (body height and mass), scores on the Yo-Yo Intermittent Recovery Test (total distance covered, TD), repeated-sprint ability (6 repetitions of 2x15-m shuttle sprints with recording of best time for a single trial, RSAbest) and performance on a complex handball test (HBKT) of throw slap (TS) and throw jump (TJ) with and without precision. RESULTS: The anthropometric data revealed a significantly lower body height for wings and pivots than for goalkeepers. Wings, pivots and goalkeepers were significantly shorter than backs, but had a similar BMI. The TD was greater for the wings (2.400 m) than for backs (1.832 m) and pivots (2.067m). Wings also achieved a better RSAbest (5.41 s) than backs (5.68 s) or pivots (5.82 s). Body height was significantly related to throw slap (TS) and jump (JT) (r=0.53, P<0.01; r=0.51, P<0.01 respectively). No significant difference (P=0.675; η2=0.009) was seen between JT with precision and JT without precision. CONCLUSIONS: Substantial differences of body build and physical performance between playing positions underline the importance of a careful assignment of such positions and the development of position-specific training for professional handball players by modifying both intermittent aerobic and anaerobic endurance components of training sessions.

Inter- and intrarater reliability of goniometry and hand held dynamometry for patients with subacromial impingement syndrome.

The purpose of this study was to examine the intra- and interrater reliability of measuring shoulder range of motion (ROM) and strength among patients diagnosed with subacromial impingement syndrome (SAIS). Twenty-five patients (14 female patients; mean age, 60.4± 7.84 years) diagnosed with SAIS were assessed to determine the intrarater reliability for glenohumeral ROM. Twenty-five patients (16 female patients; mean age, 60.4± 7.80 years) and 76 asymptomatic volunteers (52 female volunteers; mean age, 29.4± 14.1 years) were assessed for interrater reliability. Dependent variables were active shoulder ROM and isometric strength. Intrarater reliability was fair-to-excellent for the SAIS patients (intraclass correlation coefficient [ICC], 0.52-0.97; standard error of measurement [SEM], 4.4°-9.9° N; coefficient of variation [CV], 7.1%-44.9%). Based on the ICC, 11 of 12 parameters (92%) displayed an excellent reliability (ICC> 0.75). The interrater reliability showed fair-to-excellent results (SAIS patients: ICC, 0.13-0.98; SEM, 2.3°-8.8°; CV, 3.6%-37.0%; controls: ICC, 0.11-0.96; SEM, 3.0°-35.4°; CV, 5.6%-26.4%). In accordance with the intrarater reliability, glenohumeral adduction ROM was the only parameter with an ICC below 0.75 for both samples. Painful shoulder ROM in the SAIS patients showed no influence on the quality of reliability for measurement. Therefore, these protocols should be considered reliable assessment techniques in the prevention, diagnosis, and treatment of painful shoulder conditions such as SAIS.

Intrarater reliability of goniometry and hand-held dynamometry for shoulder and elbow examinations in female team handball athletes and asymptomatic volunteers.

INTRODUCTION: To evaluate the intrarater reliability for examining active range of motion (ROM) and isometric strength of the shoulder and elbow among asymptomatic female team handball athletes and a control group using a manual goniometer and hand-held dynamometry (HHD). MATERIALS AND METHODS: 22 female team handball athletes (age: 21.0 ± 3.7 years) and 25 volunteers (13 female, 12 male, age: 21.9 ± 1.24 years) participated to determine bilateral ROM for shoulder rotation and elbow flexion/extension, as well as isometric shoulder rotation and elbow flexion/extension strength. Subjects were assessed on two separate test sessions with 7 days between sessions. Relative (intraclass correlation coefficients (ICC) and standard error of measurement (SEM) reliability were calculated. RESULTS: Reliability for ROM and strength were good to excellent for both shoulders and groups (athletes: ICC = 0.94-0.97, SEM 1.07°-4.76 N, controls: ICC = 0.96-1.00, SEM = 0.00 N-4.48 N). Elbow measurements for both groups also showed good-to-excellent reliability (athletes: ICC = 0.79-0.97, SEM = 0.98°-5.94 N, controls: ICC = 0.87-1.00, SEM = 0.00 N-5.43 N). CONCLUSIONS: It is important to be able to reliably reproduce active ROM and isometric strength evaluations. Using a standardized testing position, goniometry and HHD are reliable instruments in the assessment of shoulder and elbow joint performance testing. We showed good-to-excellent reproducible results for male and female control subjects and female handball athletes, although the single parameters in ROM and strength were different for each group and between the shoulders and elbows.

Glenohumeral range of motion (ROM) and isometric strength of professional team handball athletes, part III: changes over the playing season.

INTRODUCTION: The aim of our study was to investigate the relation of workload on range of motion and isometric strength of team handball athletes' shoulders over a competitive season. MATERIALS AND METHODS: 31 Professional male handball athletes underwent clinical shoulder examinations. Athletes were examined subsequently during the complete playing season (week 0, 6, 22 and 40) to determine bilateral isometric shoulder rotational strength and active range of motion (ROM). In addition, relative (intraclass correlation coefficients (ICC) and absolute (standard error of measurement) reliability were calculated. RESULTS: Intraobserver reliability was excellent (ICC 0.76-0.98) for isometric strength and flexibility measurements. Internal rotation (IR) and total arc ROM in the throwing shoulder (TS) decreased significantly (p < 0.05) in both sequences (week 22 to week 40, week 0 to week 40). External rotation (ER) ROM and isometric strength in IR and ER did not change significantly. Glenohumeral internal rotation deficit (GIRD) and external rotation gain (ERG) of the TS decreased significantly between week 22 and week 40, but both did not change overall (week 0 to week 40). There was significant influence on IR ROM (week 22 to week 40) and strength in ER (week 0 to week 40) in the non-throwing shoulder. CONCLUSIONS: Several characteristics of handball players' shoulders changed significantly from the beginning to the end of a season. More specifically, the repetitive forces accumulated during the competitive season resulted in altered GIRD, ERG and isometric strength of the dominant glenohumeral joint.

Range of motion and isometric strength of shoulder joints of team handball athletes during the playing season, Part II: changes after midseason.

OBJECTIVE: Our objective was to investigate the influence of workload and consecutive changes on active range of motion and isometric strength of team handball athletes' throwing shoulders (TSs) because the available data are insufficient. METHODS: In a longitudinal investigation, 31 professional male handball athletes underwent a clinical shoulder examination. Athletes were examined at the beginning (week 0), at the end (week 6) of the preseasonal training, and at the end of the half-season (week 22) on both shoulders to determine isometric rotational strength (hand held dynamometer) and active range of motion (goniometer). RESULTS: This analysis demonstrates the results subsequently from week 6 to week 22 and from week 0 to week 22. The glenohumeral internal rotation (IR) deficit (GIRD), external rotation (ER) gain, and ER at the TS increased significantly (P < .05, η(2) > 0.10, d > 0.30) in the first sequence (week 6 to week 22) but not significantly from week 0 to week 22. The total range of motion remained stable, and IR changed but not significantly. There was no influence on IR, ER, and total range of motion at the non-TS. The isometric strength of the TS and non-TS IR did not change. The isometric strength in ER significantly increased bilaterally during the investigation period. CONCLUSIONS: Our data verify changes and influences, such as an increasing GIRD, at the overhead TS joint in accordance with the workload during team handball season. ER gain did improve after the half-season period but did not fully compensate the GIRD at the TS.

Reversed shoulder arthroplasty in cuff tear arthritis, fracture sequelae, and revision arthroplasty.

BACKGROUND AND PURPOSE: Reversed shoulder arthroplasty may be used for severe arthropathy where conventional prostheses cannot restore the function sufficiently. We analyzed the medium-term results and potential complications of the reversed prostheses, and also the influence of etiology on the result. METHODS; 52 women and 7 men, average age 70 (60-82) years, were followed for mean 4 (2-7) years. The indications were cuff tear arthropathy (CTA) (23), fracture sequelae (20), and revision of a failed conventional arthroplasty (16). RESULTS: The average Constant score improved from 18 (2-55) points to 59 (17-96) points. It rose from 26 to 74 points in patients with CTA, from 12 to 48 in those with fracture sequelae, and from 10 to 54 points in revision arthroplasty. We also found an overall improvement in active forward flexion from 47 degrees to 105 degrees , and in active abduction from 46 degrees to 93 degrees . Scapular notching was seen in 51 shoulders. Radiolucent lines below the base-plate were present in 2 cases. There were no instances of loosening. Revisions were necessary in 15 patients: 5 with infections (all had had prior surgery), 5 with hematoma, 3 with dislocations, and 2 with disconnections of the shaft components. INTERPRETATION: Reversed prosthetic replacement is a suitable method for restoring function and attaining pain relief in severe arthropathies. The results in revision arthroplasty are less predictable, with complications and revision rates higher than those in CTA patients. The reversed prosthesis should therefore only be used when conventional methods have failed.

Influence of a 902.4 MHz GSM signal on the human visual system: investigation of the discrimination threshold.

The proximity of a mobile phone to the human eye raises the question as to whether radiofrequency (RF) electromagnetic fields (EMF) affect the visual system. A basic characteristic of the human eye is its light sensitivity, making the visual discrimination threshold (VDThr) a suitable parameter for the investigation of potential effects of RF exposure on the eye. The VDThr was measured for 33 subjects under standardized conditions. Each subject took part in two experiments (RF-exposure and sham-exposure experiment) on different days. In each experiment, the VDThr was measured continuously in time intervals of about 10 s for two periods of 30 min, having a break of 5 min in between. The sequence of the two experiments was randomized, and the study was single blinded. During the RF exposure, a GSM signal of 902.4 MHz (pulsed with 217 Hz) was applied to the subjects. The power flux density of the electromagnetic field at the subject location (in the absence of the subject) was 1 W/m(2), and numerical dosimetry calculations determined corresponding maximum local averaged specific absorption rate (SAR) values in the retina of SAR(1 g) = 0.007 W/kg and SAR(10 g) = 0.003 W/kg. No statistically significant differences in the VDThr were found in comparing the data obtained for RF exposure with those for sham exposure.