A. Jäger

Long-Term Outcome After Arthroscopic Meniscal Repair Versus Arthroscopic Partial Meniscectomy for Traumatic Meniscal Tears

Background: The influence of standard meniscus treatment strategies regarding osteoarthritic progress, function, and sports activity has not been estimated in a direct long-term comparison. Hypothesis: Meniscal repair compared with partial meniscectomy (partial meniscal resection) decreases osteoarthritic changes and reduces the effect on sports activity in the long-term follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Eighty-one patients with an arthroscopic meniscus shape–preserving surgery after isolated traumatic medial meniscal tear (repair: n = 42; meniscectomy: n = 39) were examined clinically (Lysholm score, Tegner score) and radiologically (Fairbank score, compared with the uninjured knee); the follow-up was divided into midterm (3.4 years; n = 35) and long term (8.8 years; n = 46). Additionally, the influences of the preoperative sports activity level and age at surgery were evaluated. Results: In the long-term follow-up, no osteoarthritic progress was detectable in 80.8% after repair compared with 40.0% after meniscectomy (P = .005) with significant benefit for the “young” subgroup (P = 0.01). The preinjury activity level was obtained in 96.2% after repair compared with 50% after meniscectomy (P = .001). The function score revealed no significant difference between these strategies (P = .114). The athletes showed a significantly reduced loss of sports activity after repair compared with the athletes after meniscectomy (P = .001). Conclusion: Arthroscopic meniscal repair offers significantly improved results for isolated traumatic meniscal tears regarding the long-term follow-up in osteoarthritis prophylaxis and sports activity recovery compared with partial meniscectomy.

Relevance of arm position and muscle activity on three-dimensional glenohumeral translation in patients with traumatic and atraumatic shoulder instability.

Background No quantitative data on glenohumeral translation exist allowing one to distinguish insufficiency of the active or passive stabilizers in different forms of shoulder instability. Hypothesis To determine whether 1) in traumatic or atraumatic shoulder instability an increase of glenohumeral translation can be observed in specific relevant arm positions, 2) muscle activity leads to recentering of the humeral head, and 3) there exist differences between traumatic and atraumatic instability. Study Design Prospective clinical trial. Methods In 12 patients with traumatic and 10 patients with atraumatic instability, both shoulders were examined in different arm positions—with and without muscle activity—by using open magnetic resonance imaging and a three-dimensional postprocessing technique. Results At 90° of abduction and external rotation, translation (anterior-inferior) was significantly higher in patients with traumatic unstable shoulders compared with their contralateral side (3.6 ± 1.5 versus 0.7 ± 1.6 mm). In patients with atraumatic instability, significantly increased translation (4.7 ± 2.0 mm) was observed, with the direction being nonuniform. Muscle activity led to significant recentering in traumatic but not in atraumatic instability. Conclusions In traumatic instability, increased translation was observed only in functionally important arm positions, whereas intact active stabilizers demonstrate sufficient recentering. In atraumatic instability, a decentralized head position was recorded also during muscle activity, suggesting alterations of the active stabilizers. Clinical Relevance Clinical Relevance: These data are relevant for optimizing diagnostics and therapeutic strategies.

Shoulder Sport-Specific Impairments After Arthroscopic Bankart Repair A Prospective Longitudinal Assessment

Background: Reports of return to shoulder-dependent sport after surgical stabilization previously underestimated impairments, which were not reflected in the score systems used. Hypothesis: Return to shoulder-dependent sport depends on the type of sport performed. Study Design: Case series; Level of evidence, 4. Methods: Forty-seven athletes (26.9 years of age at surgery) who underwent isolated arthroscopic Bankart repair were longitudinally monitored by shoulder-dependent sport-specific activity (Shoulder Sport Activity Score [SSAS]) and ability (Athletic Shoulder Outcome Scoring System [ASOSS]) scores and visual analog scales for reachieved proficiency level, sport-specific shoulder pain, and functional deficits. Data were assessed at 4 points of treatment: preoperatively, and postoperatively after 6, 16, and 32 months (P0-P3). Athletes were analyzed separately according to shoulder sport: noncollision/nonoverhead (G1), collision (G2), overhead (G3), and martial arts (G4). Results: The G1 and G2 athletes had reachieved the preinjury sport activity and sport proficiency status and excellent ASOSS scores after 32 months (SSASG1 = 7.2, SSASG2 = 8.1, ASOSSG1 = 94.4, ASOSSG2 = 95.2), whereas G3 and G4 athletes remained at an inferior activity level (SSASG3 = 8.0, SSASG4 = 8.3) and proficiency level. The ASOSS documented a prolonged period of shoulder rehabilitation for G3 and G4 athletes to reach a good shoulder-dependent sport ability outcome after 32 months (ASOSSG3 = 89.0, ASOSSG4 = 93.1). All groups recorded persisting limitations in visual analog scales for sport-specific shoulder function and pain. The established scores (Rowe = 95.9, Walch-Duplay = 93.3, Constant = 94.0) did not reflect these sport-specific impairments. Athletes with 5 or more preoperative dislocations had significantly longer surgery-to-sport resumption intervals with a prolonged proficiency recovery. Conclusion: The athletes’ shoulder stabilization resulted in a prolonged rehabilitation depending on the functional demand of the performed shoulder-dependent sport, as shown by the specific shoulder sport score systems.

Kindliche vordere Kreuzbandruptur

ZusammenfassungDie Vorgehensweise bei Verletzungen des vorderen Kreuzbandes (VKB) bei noch offenen Wachstumsfugen hat sich in den letzten Jahren grundlegend geändert. Während bei der intraligamentären Ruptur die Indikation zur Ersatzplastik des VKB bis vor wenigen Jahren noch sehr zurückhaltend gestellt wurde, ist die Indikation zur operativen Behandlung der ossären Ausrisse der Eminentia klarer definiert. Die anatomiegerechte Refixation des ausgebrochenen ossären Anteils führt hier zu guten bis sehr guten Ergebnissen. Dies zeigt sich sowohl bei den transossären Nahttechniken (kleine Fragmente) als auch bei der Schraubenfixation (große Fragmente). Die Behandlung intraligamentärer Rupturen des VKB bei Patienten mit offenen Wachstumsfugen wird kontrovers diskutiert. Wir möchten zeigen, dass relevante Verletzungen selten vorkommen und meist auf technische Fehler zurückzuführen sind.AbstractThe procedural method for injury of the anterior cruciate ligament (ACL) when the epiphyseal growth plates are still open has fundamentally changed in recent years. Although the indications for surgical reconstruction of the ACL after intraligamental rupture were until recently held in reservation, the indications for operative treatment of osseous avulsion of the eminentia are more clearly defined. The anatomically correct refixation of the avulsed osseous fragment leads to good or very good results using both the transosseous suture technique (small fragments) as well as screw fixation (large fragments). The management of intrasubstance tears of the ACL in patients with open physes remains controversial. We like to show that disturbance of the growth plate is very rarely and it is often related to technical errors.

Analyse und Vergleich 2-D- vs. 3-D-Glenoidversion bei a-/traumatischer Schulterinstabilität – ist eine 3-D-Analyse notwendig?

AIM Changes in glenoid orientation as a primary cause of shoulder instability have been discussed controversially in the literature. The data of a physiological glenoid version vary widely among different authors and techniques. One reason may be that the previously used 2-D techniques suffer from a limited reproducibility and validity. The objective of this study was therefore to compare the 2-D and 3-D analyses of the glenoid version in patients with shoulder instability. METHOD The shoulders of 28 healthy volunteers and of 14 patients each with atraumatic/traumatic instability were examined in an open MR scanner (0.2 T). The 2-D glenoid version was determined using post-processing techniques according to the technique of Friedman et al. (1992). Afterwards, the 3-D glenoid version was analysed independently of the slice orientation and patient position. The coefficient of correlation (r) between the 2-D and 3-D glenoid versions was calculated using the correlation z test. RESULTS The 3-D post-processing technique showed a reproducibility with a coefficient of variation of 8.3 %. Patients with traumatic instability demonstrated no significant difference compared to the healthy control group (4.4 +/- 2.1 degrees vs. healthy: 3.9 +/- 1.3 degrees ). In atraumatic shoulder instability the glenoid retroversion was in the mean significantly increased (10.2 +/- 4.9 degrees ). The individual values ranged between 2.6 degrees and 16.6 degrees . Also for the contralateral, unaffected side a significantly increased retroversion (6.3 +/- 2.2 degrees ) was observed compared to healthy shoulders. There was a significant correlation (r: 0.84) between 2-D and 3-D retroversion. CONCLUSIONS The presented techniques allow for a reproducible assessment of glenoid version independent of the slice orientation and patient position. Our results demonstrate in the mean only a small difference of +/- 3 degrees between 2-D and 3-D glenoid versions. Therefore under standardised conditions the 2-D CT/MRI should be adequate for measuring the glenoid version except for borderline cases. No significant changes in glenoid version were found in patients with traumatic instability. In atraumatic, posterior instability, in the mean an increased retroversion was observed on both sides. However, the magnitude of these changes varied widely among individuals and should be identified to initiate a causal treatment.

Analyses and Comparison of 2-D vs. 3-D Glenoid Versions in Atraumatic/Traumatic Shoulder Instability - Are 3-D Analyses Essential?

AIM Changes in glenoid orientation as a primary cause of shoulder instability have been discussed controversially in the literature. The data of a physiological glenoid version vary widely among different authors and techniques. One reason may be that the previously used 2-D techniques suffer from a limited reproducibility and validity. The objective of this study was therefore to compare the 2-D and 3-D analyses of the glenoid version in patients with shoulder instability. METHOD The shoulders of 28 healthy volunteers and of 14 patients each with atraumatic/traumatic instability were examined in an open MR scanner (0.2 T). The 2-D glenoid version was determined using post-processing techniques according to the technique of Friedman et al. (1992). Afterwards, the 3-D glenoid version was analysed independently of the slice orientation and patient position. The coefficient of correlation (r) between the 2-D and 3-D glenoid versions was calculated using the correlation z test. RESULTS The 3-D post-processing technique showed a reproducibility with a coefficient of variation of 8.3 %. Patients with traumatic instability demonstrated no significant difference compared to the healthy control group (4.4 +/- 2.1 degrees vs. healthy: 3.9 +/- 1.3 degrees). In atraumatic shoulder instability the glenoid retroversion was in the mean significantly increased (10.2 +/- 4.9 degrees). The individual values ranged between 2.6 degrees and 16.6 degrees . Also for the contralateral, unaffected side a significantly increased retroversion (6.3 +/- 2.2 degrees) was observed compared to healthy shoulders. There was a significant correlation (r: 0.84) between 2-D and 3-D retroversion. CONCLUSIONS The presented techniques allow for a reproducible assessment of glenoid version independent of the slice orientation and patient position. Our results demonstrate in the mean only a small difference of +/- 3 degrees between 2-D and 3-D glenoid versions. Therefore under standardised conditions the 2-D CT/MRI should be adequate for measuring the glenoid version except for borderline cases. No significant changes in glenoid version were found in patients with traumatic instability. In atraumatic, posterior instability, in the mean an increased retroversion was observed on both sides. However, the magnitude of these changes varied widely among individuals and should be identified to initiate a causal treatment.

Arthroskopische Meniskusrefixierung vs. arthroskopische Meniskusteilresektion

ZusammenfassungInwieweit das hinsichtlich operativer Technik und Rehabilitation deutlich aufwendigere Verfahren der arthroskopischen Meniskusrefixierung der arthroskopischen Meniskusteilresektion im mittel- und langfristigen Outcome bzgl. der Osteoarthroseprävention überlegen ist, wird durch diese Studie in einem direkten Vergleich untersucht.Es wurden 81 Patienten mit isolierter Meniskusverletzung retrospektiv klinisch und radiologisch standardisiert untersucht, 42 Patienten der Meniskusrefixierungsgruppe (MRF) und 39 Patienten der Meniskusteilresektionsgruppe (MTR). Bei der radiologischen Untersuchung wurden beide Kniegelenke entsprechend dem Fairbank-Scoresystem evaluiert. Die Nachuntersuchungszeiträume wurden in ein mittelfristiges Follow-up (3,4 Jahre) und langfristiges Follow-up (8,9 Jahre) unterteilt. Patienten mit beidseitiger Kniegelenkverletzung, fettiger Meniskusdegeneration, Verletzungen des medialen und lateralen Meniskus an einem Knie sowie Achsfehlstellungen wurden von der Untersuchung ausgeschlossen.Bei einer identischen Erfolgsrate von 95% beider Verfahren zeigen die Langzeitergebnisse nach Meniskusrefixierung 81% im Seitenvergleich entsprechend dem Fairbank-Scoresystem keine Veränderung bzgl. osteoarthrotischer Prozesse. Dagegen sind lediglich 40% nach Meniskusteilresektion bzgl. Verschleißerscheinungen unverändert. Die mittelfristigen Ergebnisse zeigen einen geringen, nicht signifikanten Unterschied zugunsten der Meniskusrefixierungsgruppe.Die arthroskopische Meniskusrefixierung ermöglicht gegenüber der Meniskusteilresektion bei identischer Komplikationsrate hinsichtlich der Meniskusheilung eine signifikant bessere Therapieoption mit signifikant geringerem Gonarthroserisiko.AbstractThe mid-term and long-term results of meniscus refixation (MRF) versus the meniscus partial resection (MPR) have not yet been compared directly regarding osteoarthritic changes. A total of 81 patients with an isolated meniscus rupture within a stable knee after arthroscopic meniscus-preserving surgery, were physically and radiologically examined, with 42 patients in the MRF group and 39 in the MPR group. Patients with bilateral knee injuries, previous surgery, additional chondral lesions, strong valgus and/or varus deviation and fatty degenerative meniscus lesions were excluded from the investigation. The osteoarthritic changes were radiologically estimated using the Fairbank score and compared to the other uninjured knee. Retrospectively all patients were reviewed and the time of follow-up was separated into mid-term (3.4 years) and long-term (8.9 years) after arthroscopic meniscus surgery. The success rate in the long-term follow-up was 95.24% for the MRF group and 94.87% for the MPR group. With respect to osteoarthritic changes, 81% showed no changes after MRF compared to 40% after MPR after 8.9 years. The MRF group showed a slightly lower incidence of osteoarthritic changes for the mid-term results after 3.4 years, but this was not statistically significant.Arthroscopic MRF for isolated meniscus tears in the vascular zone of the stable knee offers more favourable results regarding induction of osteoarthritis compared to partial meniscus resection with an identical risk of complications.

V 44 Scoresystem und MRT-Diagnostik nach arthroskopischer Schulterstabilisierung mit Bio-Fadenankern – Zusammenhang der klinischen und radiologischer Diagnostik 12 Monate postoperativ

Fragestellung Die primare arthroskopische Stabilisierung der Schulterinstabilitat Typ Gerber B2 mit biodegradierbaren Fadenankern hat sich mittlerweile als Goldstandardtherapie etabliert, die knotenfreie Fixierungstechnik fuhrt intraoperativ zur adaquaten Adressierung der Pathologie. Am Tiermodell sowie biomechanisch sind die Implantate ausfuhrlich untersucht, hingegen sind die Bioresorption der im Glenoid implantierten Anker inkl. der ossaren Reaktion sowie das Einheilungsverhalten des adressierten Labrums am Patienten bis dato unbekannt. Diese Fragestellungen inkl. der Korrelation zu persistierend klinischen Instabilitatszeichen werden mittels eines standardisierten MRT-Protokolls und eines standardisierten Nachuntersuchungs-Verfahrens 12 Monate postoperativ untersucht. Methodik 40 Patienten (∅Alter bei Erstluxation: 24,5 J; ∅Alter bei OP: 28,1 J; ∅Anzahl praoperativer Luxationen: 5,6) wurden prospektiv 12 Mo nach standardisierter OP und Nachbehandlung klinisch und radiologisch durch ein einheitliches Protokoll untersucht. Die klinische Untersuchung (durch eine Person) erfolgte via Score-System (CM, ASES, DASH) und klinischer Instabilitatstests (Apprehension-Test, Sulcus-Sign, Relocation-Test, vorderer Schubladentest). Durch die standardisierte MRT (Stir+T1/512 cor., DE sag., PDW+PDW Spir axial; ohne KM; ein unabhangiger Radiologe) wird die Labrum-Degeneration (Grad 0 bis 3 n. Randelli), die adharente Lage des Labrums und IGHL, das Anker-Bioresorptionsverhalten (Grad 0 bis 3) sowie die glenoidale ossare Reaktion (Grad 0 bis 3 n. Hoffmann) und die Hill-Sachs-Impression (Grad 0 bis 3 n. Calandra) beurteilt. Ergebnisse Die klinische Untersuchung nach 12 Mo zeigt im Score-System gute bis sehr gute funktionelle Ergebnisse (CM=98,25; ASES=94,47; DASH=26,36). Im Mittel wurden 1,72 Anker (doppelt armiert; PushLock©, Arthrex) implantiert. Die Bioresorption (∅Grad 0,91) und die ossare Reaktion (∅Grad 0,67 n. Hoffmann) sind 12 Mo postoperativ gering, ohne osteolytische Resorptionsherde und ohne Ankerdislokation. Die geringgradige Labrumdegeneration (∅Grad 1,34 n. Randelli) ist ohne statistische Signifikanz zur praoperativen Luxationsanzahl. Nach 12 Mo besteht bei 36 von 40 Patienten eine adharente Labrumlage zw. 3 und 6 Uhr mit regelgerechter Adressierung des IGHL. Schlussfolgerungen Diese radiologisch-klinische Studie zeigt 12 Mo postop bei regelgerechter Labrum-Adressierung eine geringgradige Bioresorption ohne Ankerdislokation bzw. glenoidale Lyseherde. Die Labrumdegeneration und Morphologie des anteroinferioren Komplexes ist unabhangig von der praoperativen Luxationsanzahl.