Anja Hirschmüller

Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy

Background: The therapeutic efficacy of non-surgical treatment strategies in Achilles tendinopathy (AT) has not been well clarified. Time-consuming and costly combinations of treatment for pain, physiotherapy and biomechanical procedures are often applied. Objective: To analyse the efficacy of single therapeutic regimens commonly used over a short period of 4 weeks. Methods: 31 male runners (mileage >32 km/week) with unilateral, untreated AT completed 4 weeks of either physiotherapy (10 treatments: deep-friction, pulsed ultrasound, ice, sensory motor training; (P)), wearing custom fit semirigid insoles (I) or remained without treatment (control group C). Before and after treatment, all patients underwent a treadmill test and a plantar flexion strength exercise. Subjective pain (Pain Disability Index, Pain Experience Scale), as well as strength performance capacity (peak torque), was analysed (mean, 95% CI, repeated measures analysis of variance, α = 0.05). Results: Pain was reduced to <50% of the baseline value after physiotherapy or after wearing insoles (p<0.05). Individual pain reduction was >50% (25%) in 89% (100%) of subjects in I and 55% (73%) in P. Higher eccentric plantar flexion peak torques after treatment were observed in I and P. Conclusions: Most patients with AT experience a reduction in pain after only 4 weeks of differentiated, non-surgical treatment consisting of physiotherapy or semirigid insoles.

Repair of Focal Cartilage Defects With Scaffold-Assisted Autologous Chondrocyte Grafts Clinical and Biomechanical Results 48 Months After Transplantation

Background Scaffold-assisted autologous chondrocyte implantation is a clinically effective procedure for cartilage repair, but biomechanical evaluations are still missing. Purpose This study was conducted to assess the clinical efficacy, including biomechanical analyses, of BioSeed-C treatment for traumatic and degenerative cartilage defects of the knee. Study Design Case series; Level of evidence, 4. Methods The authors evaluated the midterm clinical and biomechanical outcome of BioSeed-C, a cell-based fibrin-polymer graft for the treatment of cartilage defects. Clinical outcome at 4-year follow-up was assessed in 52 patients with full-thickness cartilage defects, International Cartilage Repair Society (ICRS) stage III and IV. Clinical scoring was performed preoperatively and 48 months after implantation using the Lysholm score, the International Knee Documentation Committee (IKDC) score, the ICRS score, the Knee injury and Osteoarthritis Outcome Score (KOOS), and the Noyes score. Cartilage regeneration was assessed by magnetic resonance imaging (MRI) using the Henderson-Kreuz score. Biomechanical evaluation was performed by isokinetic strength measurements, comparing healthy and operated knee of each patient. Results Clinical evaluation showed significant improvement in the Lysholm (from 51.8 preoperatively to 80.7 at 48 months postoperatively), IKDC (from 47.5 to 71.5), ICRS (from 3.8 to 2.0), KOOS (subcategory pain from 62 to 78, symptoms from 68 to 76, activities of daily living from 68 to 85, sports from 19 to 55, and quality of life from 30 to 55), and Noyes (from 31 to 59) scores (P ≤ .001) 48 months after implantation of BioSeed-C compared with the preoperative situation. The MRI evaluations showed moderate to complete defect filling in 43 of 44 treated patients. Two patients without improvement in the clinical and MRI scores received a total knee endoprosthesis after 4 years. Isokinetic evaluation showed significantly reduced maximum strength capacities for knee flexion and extension at the operated knee compared with the healthy knee (P < .05). Conclusion The clinical outcomes 4 years after graft implantation are good despite a persisting strength deficit. Implanting Bio-Seed-C is a promising treatment option for cartilage defects of the knee. More emphasis should be put on the rehabilitation of muscular strength.

Treatment of periprosthetic femoral fractures with two different minimal invasive angle-stable plates: Biomechanical comparison studies on cadaveric bones

INTRODUCTION The introduction of fixed-angle plate osteosynthesis techniques has provided us a further means to treat periprosthetic femoral fractures. The goal of this experimental study is to evaluate the biomechanical properties and stability of treated periprosthetic fractures when using two different plate systems, which vary in the locking mechanism and the screw placement (monocortical or bicortical) with respect to the prosthesis stem. MATERIALS AND METHODS Using five pairs of formalin-fixed femora, a Vancouver B1 periprosthetic fracture was treated either with a 13-hole LISS(®) titanium plate using four monocortical periprosthetic screws or with a non-contact bridging plate (NCB) DF(®) plate using bicortical angle-stable blocked screws positioned ventrally or dorsally to the prosthesis stem. Bones were loaded under axial and cyclic compression with a progressively increased load until failure. Displacement at the osteotomy gap was measured during loading using an ultra-sound measuring system. RESULTS The mean displacement in the region of the fracture gap was not significantly different at any time during the experiments for the two models. The mean force resulting in subsequent model failure was similar in both models; the failure morphology varied slightly between the models, however. Four of the five LISS(®) models exhibited either a tear-out of the monocortical screws or a decortication from the bony shaft of the cortical lamella surrounding the screws. On the other side, two of the NCB models showed macroscopically visible fissures along the osteosynthesis plates at the height of the osteotomy gap, and were hence considered implant failures. Only one NCB model showed tear-out of the bicortically placed screws. CONCLUSION Bicortical screw placement provides more stable anchoring when compared to monocortical screw fixation. However, in relation to the amount of motion at the osteotomy gap and to failure loads, stabilisation of periprosthetic femoral fractures can be equally well achieved using either the LISS(®) plate with periprosthetic monocortical screws or the NCB plate with poly-axially placed bicortical screws.

Rehabilitation After Autologous Chondrocyte Implantation for Isolated Cartilage Defects of the Knee

Autologous chondrocyte implantation for treatment of isolated cartilage defects of the knee has become well established. Although various publications report technical modifications, clinical results, and cell-related issues, little is known about appropriate and optimal rehabilitation after autologous chondrocyte implantation. This article reviews the literature on rehabilitation after autologous chondrocyte implantation and presents a rehabilitation protocol that has been developed considering the best available evidence and has been successfully used for several years in a large number of patients who underwent autologous chondrocyte implantation for cartilage defects of the knee.

Finite element analysis of four different implants inserted in different positions to stabilize an idealized trochanteric femoral fracture

Biomechanical analysis of the ideal placement of new intramedullary implants for stabilization of trochanteric fractures is not currently available. The aim of the presented study is to determine to what extent four intermedullary nails (Gliding-Nail, Gamma-Nail, PFN-A and Targon-PF), inserted in different positions, differ mechanically. A proximal femur was reconstructed on the basis of clinical CT data as a surface model. Load application equivalent to the one-leg stance phase during gait was assumed, taking into account a limited number of active muscle forces. The four implants were inserted cranially and caudally into the bone structure and a model of a trochanteric fracture was created. Criteria with point ratings were introduced to quantify a favourable fracture healing situation. Finite element simulation showed clear differences between the different implants with regard to the distributions of stress and strain at the two fracture surfaces in the model and the von Mises stress in the implant itself. It was apparent for three implants under investigation that the caudal position generated better fracture healing conditions than the cranial position. Only the Targon PF demonstrated better fracture healing conditions in the cranial position. Evaluation based on the point rating system revealed that the caudal position was the ideal position for the PFN-A, Gamma-Nail and Gliding-Nail. The Targon-PF demonstrated some advantages over the other implants in the caudal position.

Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes.

Achilles (AT) and patellar tendons (PT) are commonly affected by tendinopathy in adult athletes but prevalence of symptoms and morphological changes in adolescents is unclear. The study aimed to determine prevalence of tendinopathy and intratendinous changes in ATs and PTs of adolescent athletes. A total of 760 adolescent athletes (13.0 ± 1.9 years; 160 ± 13 cm; 50 ± 14 kg) were examined. History, local clinical examination, and longitudinal Doppler ultrasound analysis for both ATs and PTs were performed including identification of intratendinous echoic changes and vascularization. Diagnosis of tendinopathy was complied clinically in case of positive history of tendon pain and tendon pain on palpation. Achilles tendinopathy was diagnosed in 1.8% and patellar tendinopathy in 5.8%. Vascularizations were visible in 3.0% of ATs and 11.4% of PTs, hypoechogenicities in 0.7% and 3.2% as well as hyperechogenicities in 0% and 0.3%, respectively. Vascularizations and hypoechogenicities were statistically significantly more often in males than in females (P ≤ 0.02). Subjects with patellar tendinopathy had higher prevalence of structural intratendinous changes than those without PT symptoms (P ≤ 0.001). In adolescent athletes, patellar tendinopathy is three times more frequent compared with Achilles tendinopathy. Longitudinal studies are necessary to investigate physiological or pathological origin of vascularizations and its predictive value in development of tendinopathy.

Reactivity, stability, and strength performance capacity in motor sports.

Background: Racing drivers require multifaceted cognitive and physical abilities in a multitasking situation. A knowledge of their physical capacities may help to improve fitness and performance. Objective: To compare reaction time, stability performance capacity, and strength performance capacity of élite racing drivers with those of age-matched, physically active controls. Methods: Eight élite racing drivers and 10 physically active controls matched for age and weight were tested in a reaction and determination test requiring upper and lower extremity responses to visual and audio cues. Further tests comprised evaluation of one-leg postural stability on a two-dimensional moveable platform, measures of maximum strength performance capacity of the extensors of the leg on a leg press, and a test of force capacity of the arms in a sitting position at a steering wheel. An additional arm endurance test consisted of isometric work at the steering wheel at +30° and −30° where an eccentric threshold load of 30 N.m was applied. Subjects had to hold the end positions above this threshold until exhaustion. Univariate one way analysis of variance (α  =  0.05) including a Bonferroni adjustment was used to detect group differences between the drivers and controls. Results: The reaction time of the racing drivers was significantly faster than the controls (p  =  0.004). The following motor reaction time and reaction times in the multiple determination test did not differ between the groups. No significant differences (p>0.05) were found for postural stability, leg extensor strength, or arm strength and endurance. Conclusions: Racing drivers have faster reaction times than age-matched physically active controls. Further development of motor sport-specific test protocols is suggested. According to the requirements of motor racing, strength and sensorimotor performance capacity can potentially be improved.

Do changes in dynamic plantar pressure distribution, strength capacity and postural control after intra-articular calcaneal fracture correlate with clinical and radiological outcome?

UNLABELLED Fractures of the calcaneus are often associated with serious permanent disability, a considerable reduction in quality of life, and high socio-economic cost. Although some studies have already reported changes in plantar pressure distribution after calcaneal fracture, no investigation has yet focused on the patients strength and postural control. METHOD 60 patients with unilateral, operatively treated, intra-articular calcaneal fractures were clinically and biomechanically evaluated >1 year postoperatively (physical examination, SF-36, AOFAS score, lower leg isokinetic strength, postural control and gait analysis including plantar pressure distribution). Results were correlated to clinical outcome and preoperative radiological findings (Böhler angle, Zwipp and Sanders Score). RESULTS Clinical examination revealed a statistically significant reduction in range of motion at the tibiotalar and the subtalar joint on the affected side. Additionally, there was a statistically significant reduction of plantar flexor peak torque of the injured compared to the uninjured limb (p<0.001) as well as a reduction in postural control that was also more pronounced on the initially injured side (standing duration 4.2±2.9s vs. 7.6±2.1s, p<0.05). Plantar pressure measurements revealed a statistically significant pressure reduction at the hindfoot (p=0.0007) and a pressure increase at the midfoot (p=0.0001) and beneath the lateral forefoot (p=0.037) of the injured foot. There was only a weak correlation between radiological classifications and clinical outcome but a moderate correlation between strength differences and the clinical questionnaires (CC 0.27-0.4) as well as between standing duration and the clinical questionnaires. Although thigh circumference was also reduced on the injured side, there was no important relationship between changes in lower leg circumference and strength suggesting that measurement of leg circumference may not be a valid assessment of maximum strength deficits. Self-selected walking speed was the parameter that showed the best correlation with clinical outcome (AOFAS score). CONCLUSION Calcaneal fractures are associated with a significant reduction in ankle joint ROM, plantar flexion strength and postural control. These impairments seem to be highly relevant to the patients. Restoration of muscular strength and proprioception should therefore be aggressively addressed in the rehabilitation process after these fractures.

Digital templating in total knee and hip replacement: an analysis of planning accuracy.

PurposeThe aim of this study was to determine how well pre-operative size selection for total knee and hip arthroplasties based on the digital imaging with and without additional referencing correlated with the size actually implanted.MethodsSize selection planning of total knee arthroplasty by digital templating was documented in 46 cases with reference ball (group A) and in 48 cases without ball (group B). In addition, prospective analysis of pre-operative planning was conducted for 52 acetabular components with reference ball (group C) and 69 without ball (group D) as well as stem planning in 38 cases with ball (group E) and 54 cases without ball (group F). The data were analysed and compared with the size of the final component selected during surgery.ResultsThe correlation between planned and implanted size for total knee arthroplasty in group A resulted in femoral anteroposterior (AP) r = 0.8622 and lateral r = 0.8333 and in group B AP r = 0.4552 and lateral r = 0.6950. Tibial in group A was AP r = 0.9030 and lateral r = 0.9074 and in group B AP r = 0.7000 and lateral r = 0.6376. For the acetabular components, the results in group C were r = 0.5998 and group D r = 0.6923. For stems, group E was r = 0.5306 and group F r = 0.5786. No correlation between BMI and the difference between planned and implanted size was found in any of the groups.ConclusionIn the case of total hip arthroplasty there was a relatively low correlation between planned and implanted sizes with or without reference ball. For total knee arthroplasties the already high precision of size planning was further improved by the additional referencing with a reference ball.

Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study

Background and objectives Treatment of chronic running-related overuse injuries by orthopaedic shoe orthoses is very common but not evidence-based to date. Hypothesis Polyurethane foam orthoses adapted to a participants barefoot plantar pressure distribution are an effective treatment option for chronic overuse injuries in runners. Design Prospective, randomised, controlled clinical trial. Intervention 51 patients with running injuries were treated with custom-made, semirigid running shoe orthoses for 8 weeks. 48 served as a randomised control group that continued regular training activity without any treatment. Main outcome measures Evaluation was made by the validated pain questionnaire Subjective Pain Experience Scale, the pain disability index and a comfort index in the orthoses group (ICI). Results There were statistically significant differences between the orthoses and control groups at 8 weeks for the pain disability index (mean difference 3.2; 95% CI 0.9 to 5.5) and the Subjective Pain Experience Scale (6.6; 2.6 to 10.6). The patients with orthoses reported a rising wearing comfort (pre-treatment ICI 69/100; post-treatment ICI 83/100) that was most pronounced in the first 4 weeks (ICI 80.4/100). Conclusion Customised polyurethane running shoe orthoses are an effective conservative therapy strategy for chronic running injuries with high comfort and acceptance of injured runners.