Holger Schmitt

Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes.

Anterior cruciate ligament (ACL) reconstruction in double-bundle technique is advocated to more closely restore the anatomy and function of the native ligament than conventional single-bundle technique. But up to now there are only a few clinical investigations comparing both techniques in a prospective manner. We hypothesized that double-bundle ACL reconstruction reveals superior clinical and subjective results compared to single-bundle technique in a high-demand collective. A total of 50 male patients (mean age 29.4xa0years) were prospectively randomized consecutively into one of the two reconstruction techniques. Group 1 (SB) underwent a 4-stranded single-bundle reconstruction with a ST graft in femoral position at 10:00 and 02:00 o’clock, respectively. In group 2 (DB), reconstruction was performed by using a 2-stranded ST graft with double-bundle, four tunnel technique. Before surgery and at a 2xa0year follow-up (range 23–25xa0months) patients were evaluated by the same blinded observer. There was no significant difference in the side-to-side anterior laxity-measurement with the KT-1000 between both groups. As evaluated by the pivot shift, no significant correlation could be noted (Fisher exact test Pxa0=xa00.098) between rotational stability and any of the both reconstruction techniques. However, the anterior and rotational stability improved significantly at 2-year follow-up compared to preoperatively (Pxa0=xa00.003) in both groups. The statistical analysis showed a significant increase for the IKDC (subjective, objective) and the Lysholm Score at final follow-up among each single technique, while we found no significant difference between the two reconstruction methods. On the basis of our investigation, we conclude that reconstruction of the ACL by a double-bundle ST graft with an extracortical anchorage can achieve excellent clinical results. But in contrast to our initial hypothesis, we could not quote any significant advantages by creating two independent bundles. Reconstruction of the anterior cruciate ligament in conventional single-bundle technique with a more horizontal femoral tunnel placement obtains comparable clinical results in the present high-demand collective.

Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment.

Objective:This report evaluates the subjective, clinical, and functional long-term results comparing surgical and conservative treatment in patients with a primary traumatic patellar dislocation. Design and Setting:This retrospective clinical study focuses on patients with primary acute traumatic patellar dislocation. Patients with radiologic signs indicative of a predisposition for recurrent patellar instability were excluded from this study. Patients:A total of 126 patients were examined a mean of 8.1 years after initial treatment of their primary patellar dislocation. Interventions and Main Outcome Measurements:Patients were retrospectively divided into groups with conservative therapy (n = 63), diagnostic arthroscopy only (n = 20), immediate surgical reconstruction of the parapatellar ligament complex (n = 37), and refixation of osteochondral fragments (n = 6). Redislocation and resurgery rate, activity level, and subjective, clinical, and functional results were evaluated in these patients, and the outcomes in these groups were compared. Results:In the long term, functional results (as expressed in the Lysholm score) were excellent or good in 85% of the patients, and good subjective results were reported by 71%, but follow-up revealed a recurrence rate of 26% in the total study population. The high activity level before the initial trauma could not be completely regained after treatment. There was no significant difference between the surgically and conservatively treated groups in the redislocation and reoperation rates, level of activity, or functional and subjective outcomes. Conclusions:Even with a focus on acute traumatic etiology and when factors predisposing to recurrent instability are largely excluded, the redislocation rate after treatment of acute patellar dislocation is still high, despite good clinical and subjective results. Conservative management seems to be the treatment of choice in patients with acute patellar dislocation, provided that the generally accepted indications for surgery, such as evidence of osteochondral fragments and major defects of the parapatellar ligament complex, are given due consideration.

Reconstructive versus non-reconstructive treatment of anterior cruciate ligament insufficiency. A retrospective matched-pair long-term follow-up

In this retrospective case series 80 patients divided in 40 matched pair groups with an arthroscopically proven ACL insufficiency were followed up for 15 years. One half was reconstructed using an autologous BTB patella graft, the other half was treated by a conservative physiotherapeutic based rehabilitation program. At follow-up the clinical scores (Lysholm, IKDC) showed no significant differences between subjects who had undergone ACL reconstruction and those who had not. Furthermore there was no detectable difference in the incidence of osteoarthritis between the cohorts. Patients having a negative pivot shift test showed significantly less signs of radiographic osteoarthritis and better functional assessment scores whether reconstructed or not. Based on these results and a review of the literature there is no clear evidence that ACL reconstruction reduces the rate of OA development or improves the long-term symptomatic outcome. Probably review of reconstruction by an anatomical approach will be more successful than operative techniques decades ago.

Transphyseal reconstruction of the anterior cruciate ligament in prepubescent athletes.

ACL reconstruction in adolescents undergoing or being beyond the final growth spurt can be performed as in adults without major concern of growth disturbance. Whereas for the young athlete with wide-open physis a lot of controversy still exists about the technical aspect of the procedure to minimise the risk of growth disturbance. Between 10/1997 and 10/2002 31 children graded Tanner stage 1 or 2 (median age 11xa0years) with an intraligamental rupture of the anterior cruciate ligament were enrolled. Seventeen patients with coexisting intraarticular damage (meniscus, osteochondral flake) underwent transphsyeal reconstruction of the ACL with the use of an autogenous semitendinosus tendon graft, whereas 14 patients without coexisting pathologies received a nonoperative regime. Growth disturbance, functional and radiographic outcome could be evaluated in 28 patients at a median of 70xa0months after initial treatment. No patient had clinical or radiological evidence for varus/valgus malalignment or leg length discrepancy. The mean of subsequent body growth within the study population was 20.3xa0cm. Patients operated on revealed significant (Pxa0<xa00.05) better clinical (KT-1000 side-to-side difference, pivot shift) and functional results according to the IKDC (median, 95 vs. 87), Lysholm (median, 93 vs. 84) and the Tegner score. More than half of the conservatively treated patients (58%) had subsequent surgery due to persistent instability. Transphyseal reconstruction of intraligamental ACL ruptures with an autologous ST graft yielded superior clinical results if compared to a nonoperative treatment in immature prepubescent patients being Tanner stage 1 and 2.

Prognostic value of chondral defects on the outcome after arthroscopic treatment of acetabular labral tears

Pathology of the acetabular labrum plays an increasing role in the treatment of hip pain. Hip arthroscopy has proven its clinical value as a useful procedure for successful treatment of labral tears. Until today, only a few studies have investigated the influence of articular cartilage defects on the clinical outcome of partial arthroscopic labrum resection in a larger patient population. We prospectively evaluated patients with an intraoperatively proven labral lesion/tear without any radiological and arthroscopical sign of a concomitant bony femoroacetabular impingement or hip dysplasia for a minimum postoperative follow-up of 2xa0years. Cartilage defects were classified according to Outerbridge and divided into two subgroups: Outerbridgexa0≤xa01 and Outerbridgexa0≥xa02, respectively. To evaluate combined results, various established scoring systems (visual analogue scale, modified Harris Hip Score, Larson Hip Score) were used. Out of 54 originally enrolled patients, 50 individuals (29 female, 21 male) with a median age of 33xa0years (range 15–49) were available for follow-up after a mean of 34 (range 24–48) months. At follow-up, the total study population experienced significant improvement in pain and in the combined evaluation scales (Larson Hip Score/MHHS). When patients were categorized into two subgroups, either with intraoperatively present or absent articular cartilage defects, our data indicated that subjects with no degenerative changes of the articular cartilage surface significantly improved in the applied clinically scoring systems. In contrast, in patients with an articular cartilage lesion during hip arthroscopy score values had a tendency to be unimproved or even deteriorated at follow-up. Regression analysis revealed a significant negative correlation between postoperative outcome and the grading of the coexistent articular cartilage defect. On the basis of our investigation, we conclude that partial arthroscopic resection of a torn labrum without attending bone deformity (dysplasia or femoroacetabular impingement) can reveal good and satisfied results. Depending on the extent of a coexisting articular cartilage defect subjective clinical results are compromised.

Influence of professional dance training on peak torque and proprioception at the ankle.

Objective:To investigate the influence of professional dance training on the peak torque ratio of plantar flexion to dorsiflexion (PF/DF), angle replication ability, and balance in comparison to age-matched and gender-matched controls. The effects of injuries sustained before and during the study time period were also assessed. Design:Prospective age-matched and gender-matched nonrandomized intervention study. Setting:Premises of the Orthopedic University Hospital, Heidelberg, where measuring apparatus belonging to the hospital was used for the tests. Participants:One group of 42 dancers (31 female, 11 male) in professional training (State Academy) and 40 age-matched and gender-matched controls with no prior dance or specific sport training. Main Outcome Measurements:Isokinetic tests for peak torque at 30°/s and 120°/s, a passive angle-replication test (Biodex system 3), and a test of 1-legged standing were each carried out on 2 measurement dates (M1, M2): at the beginning of a season of professional dance training (M1) and after 5 months of such training (M2). Symptoms and/or injuries sustained during this period were ascertained continuously by means of questionnaires and interviews. Results:A significant increase in peak torque in PF was observed in both dancer groups and male controls between M1 and M2. A significant increase in PF/DF peak torque ratio at 30°/s was observed in both male groups between M1 and M2. At M2, no significant differences in PF/DF peak torque ratio could be found between male dancers and controls, but at 30°/s between the female groups. However, in both female groups, the PF/DF ratio was not found to increase significantly between M1 and M2. In the angle-replication and 1-legged standing test, no consistent improvement was observed between M1 and M2 in either dancers or controls. In the angle-replication test, there were no significant differences between dancers and controls at M2. In the 1-legged standing test, the dancers did significantly better than controls. A total of 7 ankle injuries were recorded, but no difference was found between injured and uninjured subjects in the proprioceptive tests either at M1, as the predicator, or at M2 as the residual. Conclusions:Dance training did not increase the peak torque ratio of PF/DF within 5 months, but a group difference was found between the women groups. Ballet training alone without concurrent additional coordinative training does not lead to improvements in ankle joint position sense or improved measures of balance within this period of observation.

Radiographic Changes in the Lumbar Spine in Former Elite Athletes

Study Design. The authors conducted a retrospective cohort study. Objective. The objective of this study was to clarify the occurrence of radiographic changes (vertebral osteophytes, heights of lumbar discs, concavity index) of the lumbar spine in former elite athletes of different track and field disciplines. Summary of Background Data. The influence of physical activity on occurrence of radiographic changes in the lumbar spine is not well known and seems to be contradictory. The loadings in the different track and field disciplines seem to play an important role in the development of radiographic changes. Methods. One hundred fifty-nine former male elite track and field athletes were selected for a radiologic study. The heights of lumbar discs, the concavity index, the presence of anterior vertebral osteophytes, a radiographic evaluation according to Kellgren and Lawrence, and the FFbH-R score for the assessment of functional limitations in activities of daily living (ADLs) were determined. The influence of age, body mass index, current physical activity, and training history was also examined. Results. In high jumpers and throwers, the absolute heights of lumbar discs increased from level T12/L1 to a maximum at L4/L5 and decreased again from level L4/L5–L5/S1. In endurance athletes and other jumpers, the absolute heights increased linearly from level T12/L1 to a maximum at L5/S1. The concavity index did not yield any significant differences between athlete categories. Shot putters, discus throwers, and high jumpers showed a significantly higher prevalence of osteophytes after adjustment for possible confounders. According to Kellgren and Lawrence, the highest prevalence of radiographic changes in the lumbar spine is seen in javelin throwers. Significant differences in the assessment of functional limitations in ADLs are not found between the disciplines. Conclusion. In throwing disciplines, the lumbar spine is more highly loaded than in jumpers and runners. Despite the observation of evident degenerative changes in some former athletes, there were only minor changes seen in ADLs. Even if body constitution is taken as a preselection factor, athletes in throwing disciplines as well as high jumpers have a higher risk of developing vertebral osteophytes of the lumbar spine.

The association between social factors, employment status and self-reported back pain – A representative prevalence study on the German general population

AimThe medical and economic impact of back pain in terms of health care costs, lost working days, and early retirement is on the increase in Western industrialised nations. This paper investigates the prevalence of back pain in the German general population and the relationship between social factors, employment status and back pain.Subjects and methodsThe first German Health Survey comprised a representative total sample of 6,235 persons between the ages of 18 and 79. The relationship between back pain and social, lifestyle and workplace-related factors was investigated using multivariable logistic regression analyses.ResultsThe 7-day prevalence for back pain in Germany was found to be 36%, and the 1-year prevalence was 59%. The prevalence rates were significantly higher in women, lower socio-economic classes, non-athletes, smokers and those who are overweight. Depressed mood and allergies co-occurred with back pain more frequently than by chance.ConclusionThis study reports the first representative prevalence data for back pain, and its correlates and associations for the German general population.

The UniSpacer™: correcting varus malalignment in medial gonarthrosis

While options for operative treatment of leg axis varus malalignment in patients with medial gonarthrosis include several established procedures, such as unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA) or high tibial osteotomy (HTO), there has been little focus on a less invasive option introduced more recently: the UniSpacer™ implant, a self-centering, metallic interpositional device for the knee. This study evaluates clinical and radiological results of the UniSpacer™, whether alignment correction can be achieved by UniSpacer™ arthroplasty and alignment change in the first five postoperative years. Anteroposterior long leg stance radiographs of 20 legs were digitally analysed to assess alignment change: two relevant angles and the deviation of the mechanical axis of the leg were analysed before and after surgery. Additionally, the change of the postoperative alignment was determined one and five years postoperatively. Analysing the mechanical tibiofemoral angle, a significant leg axis correction was achieved, with a mean valgus change of 4.7u2009±u20091.9°; a varus change occurred in the first postoperative year, while there was no significant further change of alignment seen five years after surgery. The UniSpacer™ corrects malalignment in patients with medial gonarthrosis; however, a likely postoperative change in alignment due to implant adaptation to the joint must be considered before implantation. Our results show that good clinical and functional results can be achieved after UniSpacer™ arthroplasty. However, four of 19 knees had to be revised to a TKA or UKA due to persistent pain, which is an unacceptably high revision rate when looking at the alternative treatment options of medial osteoarthritis of the knee.

Biochemical markers in the diagnosis of chondral defects following anterior cruciate ligament insufficiency

PurposeThe aim of this study was to determine the value of systemic biochemical markers of bone turnover—urine levels of cross-linked C-terminal telopeptide I (uCTX-I), urinary C-terminal telopeptide II (uCTX-II) and serum cartilage oligomeric matrix protein (sCOMP)—in the diagnosis of chondral defects after anterior cruciate ligament (ACL) rupture. Thirty-eight patients with previous ACL rupture were included.MethodsMagnetic resonance imaging (MRI) of the injured and the intact knee joint was performed with volumetric measurement of volume and area of cartilage (VC/AC), area of subchondral bone (cAB), and area of subchondral bone denuded and eroded (dAB). Biochemical markers were measured using commercially available enzyme-linked immunoassays. ResultsMRI-based volumetric cartilage measurement showed significant differences between the injured and the intact knees. uCTX-I, sCOMP and in parts uCTX-II correlated well with MRI parameters. CTX-I showed a significant correlation with VC and AC of the whole knee joint.ConclusionsThe results suggest that uCTX-I, uCTX-II and sCOMP could identify patients with focal cartilage lesions from an early stage of osteoarthritis of the knee.