Olaf Lorbach

Nonoperative management of adhesive capsulitis of the shoulder: Oral cortisone application versus intra-articular cortisone injections

HYPOTHESISnOral and intra-articular injections of cortisone will lead to significant improvement and comparable results in the treatment of adhesive capsulitis of the shoulder.nnnMATERIALS AND METHODSnIn a prospective randomized evaluation, 40 patients with idiopathic adhesive capsulitis of the shoulder were treated with an oral corticoid treatment regimen or 3 intra-articular injections of corticosteroids. Follow-up was after 4, 8, and 12 weeks, and 6 and 12 months. For the clinical evaluation, the Constant-Murley (CM) score, the Simple Shoulder Test (SST) and visual analog scales (VAS) for pain, function, and satisfaction were used.nnnRESULTSnIn the patients treated with oral glucocorticoids, significant improvements were found for the CM score (P < .0001), SST (P=.035), VAS (P < .0001), and range of motion (P < .05) at the 4-week follow-up. The patients treated with an intra-articular glucocorticoid injection series also significantly improved in the CM score (P < .0001), SST (P < .0001), the VAS (P < .0001), and range of motion (P < .05) after 4 weeks. These results were confirmed at all other follow-up visits. Superior results were found for intra-articular injections in range of motion, CM score, SST, and patient satisfaction (P < .05). Differences in the VAS for pain and function were not significant (P > .05).nnnDISCUSSIONnThe use of cortisone in the treatment of idiopathic shoulder adhesive capsulitis leads to fast pain relief and improves range of motion. Intra-articular injections of glucocorticoids showed superior results in objective shoulder scores, range of motion, and patient satisfaction compared with a short course of oral corticosteroids.

Comparable Biomechanical Results for a Modified Single-Row Rotator Cuff Reconstruction Using Triple-Loaded Suture Anchors Versus a Suture-Bridging Double-Row Repair

PURPOSEnTo compare the biomechanical properties and footprint coverage of a single-row (SR) repair using a modified suture configuration versus a double-row (DR) suture-bridge repair in small to medium and medium to large rotator cuff tears.nnnMETHODSnWe created 25- and 35-mm artificial defects in the rotator cuff of 24 human cadaveric shoulders. The reconstructions were performed as either an SR repair with triple-loaded suture anchors (2 to 3 anchors) and a modified suture configuration or a modified suture-bridge DR repair (4 to 6 anchors). Reconstructions were cyclically loaded from 10 to 60 N. The load was increased stepwise up to 100, 180, and 250 N. Cyclic displacement and load to failure were determined. Furthermore, footprint widths were quantified.nnnRESULTSnIn the 25-mm rupture, ultimate load to failure was 533 ± 107 N for the SR repair and 681 ± 250 N for the DR technique (P ≥ .21). In the 35-mm tear, ultimate load to failure was 792 ± 122 N for the SR reconstruction and 891 ± 174 N for the DR reconstruction (P ≥ .28). There were no statistically significant differences for both tested rupture sizes. Cyclic displacement showed no significant differences between the tested configurations at 60 N (P = .563), 100 N (P = .171), 180 N (P = .211), and 250 N (P = .478) for the 25-mm tear. For the 35-mm tear, cyclic displacement showed significantly lower gap formation for the SR reconstruction at 180 N (P = .037) and 250 N (P = .020). No significant differences were found at 60 N (P = .296) and 100 N (P = .077). A significantly greater footprint width (P = .028) was seen for the DR repair (16.2 mm) compared with the SR repair (13.8 mm). However, both reconstructions were able to achieve complete footprint coverage compared with the initial footprint.nnnCONCLUSIONSnThe tested SR repair using a modified suture configuration was similar in load to failure and cyclic displacement to the DR suture-bridge technique independent of the tested initial sizes of the rupture. The tested DR repair consistently restored a larger footprint than the SR method. However, both constructs achieved complete footprint coverage.nnnCLINICAL RELEVANCEnSR repairs with modified suture configurations might combine the biomechanical advantages and increased footprint coverage that are described for DR repairs without increasing the overall costs of the reconstruction.

Influence of the Anteromedial and Posterolateral Bundles of the Anterior Cruciate Ligament on External and Internal Tibiofemoral Rotation

Background The influence of the anteromedial and posterolateral bundles of the anterior cruciate ligament on tibiofemoral rotation might be of great value to detect anterior cruciate ligament injuries and investigate the postoperative restoration of rotational stability. Hypothesis The anterior cruciate ligament and especially the posterolateral bundle will have a significant influence on isolated tibiofemoral rotation. Study Design Controlled laboratory study. Methods Tibiofemoral rotation was measured in 20 human cadaveric knees using a noninvasive external measurement device (Rotameter) and a knee navigation system. The measurements of the knees with the intact anterior cruciate ligament were compared with the measurements after isolated resection of the posterolateral bundle and after a complete resection of the anterior cruciate ligament at an applied torque of 5,10, and 15 N·m. Statistical analysis was made using analysis of variance and the post hoc Scheffé test. The Pearson coefficient was used to compare both measurement techniques. Results In comparison with knees with an intact anterior cruciate ligament, the knees after isolated resection of the posterolateral bundle showed significant increase of tibiofemoral rotation at almost all applied torques (P < .05). Total resection of the anterior cruciate ligament also produced significant increases compared with the intact anterior cruciate ligament at torques of 5, 10, and 15 N·m as measured by the Rotameter (P < .05). Total resection of the anterior cruciate ligament yielded increases in rotation compared with posterolateral bundle resection alone, but these differences were not significant. The results of the knee navigation system confirmed the measured results of the Rotameter. Comparison of the 2 measurement methods revealed a high correlation at all applied torques, with Pearson correlation coefficients ranging from .85 to .95. Conclusion The anterior cruciate ligament and especially the posterolateral bundle of the anterior cruciate ligament have a significant effect on isolated tibiofemoral rotation. Therefore, the developed noninvasive device might be of great importance to investigate the status and the postoperative reconstruction of the anterior cruciate ligament in the clinical setting. Clinical Relevance Noninvasive measurement of tibiofemoral rotation might be useful to detect anterior cruciate ligament tears and to evaluate the restoration of rotational stability after anterior cruciate ligament surgery.

Reliability testing of a new device to measure tibial rotation

The purpose of this study was to evaluate the reliability of a new developed device to measure tibial rotation, the Rotameter. Thirty healthy subjects (15xa0males, 15xa0females, 24xa0years) were examined with the Rotameter measurement device. External and internal rotation was performed at an applied torque of 5, 10 and 15xa0Nm by two independent examiners in order to test the inter-observer reliability. The patients were measured again after a mean of 31xa0±xa043xa0days by the same examiners to test the intra-observer reliability. Statistical analysis was performed using the intra-class correlation coefficient. The Pearson Correlation coefficient was used to compare the measurements of the left with the right side of the participants. In the measurements, a high inter- and intra-observer reliability was found at 5, 10 and 15xa0Nm of applied torque for the external rotation, internal rotation and the rotational range (internalxa0+xa0external rotation). Comparison of the left and the right knee of the same participant also revealed high correlations in the Pearson correlation coefficient at all applied torques. In conclusion, the Rotameter testing device for the measurement of tibial rotation showed a high inter-observer and intra-observer reliability. It is easy to perform and might be used in a wide field as a non-invasive instrument to objectively determine rotational stability and to investigate the restoration of the rotational stability after surgical procedures.

A non-invasive device to objectively measure tibial rotation: verification of the device.

The purpose of this study was the correlation of the results of a new measurement device for tibial rotation (Rotameter) in comparison with the measurements of a knee navigation system as standard method. In a biomechanical laboratory study, all soft tissues were removed from 20 human cadaveric knees leaving only the intact capsule and the bone. Specific tracers were bicortically fixed in the bone in order to measure tibial rotation using a knee navigation system. The knees were fixed to a custom-made inside-boot to rule out undesirable rotation of the reconstruction inside the Rotameter measurement device. Internal and external rotation values were measured at an applied torque of 5, 10 and 15xa0Nm. The different methods to evaluate tibial rotation were compared using the Pearson correlation coefficient. The correlations were deemed to be reliable if a value of ≥0.80 was achieved. At 5xa0Nm of applied torque, high correlations for the internal rotation, external rotation and the entire rotational range were found in the Pearson correlation coefficient between the Rotameter testing device in comparison with the knee navigation system as invasive reference method. These results were also confirmed at an applied torque of 10 and 15xa0Nm. In conclusion, the Rotameter testing device showed high correlations compared with the knee navigation system as an invasive standard method. It might be used as a non-invasive and easy alternative to investigate tibial rotation.

Static rotational and sagittal knee laxity measurements after reconstruction of the anterior cruciate ligament

PurposeThe goal of the present study was to evaluate static anteroposterior and rotational knee laxity after ACL reconstructions with two noninvasive measurement devices by comparing the measured results of the operated with the contralateral healthy knees of the patients.MethodsFifty-two consecutive patients were reviewed after isolated single-bundle transtibial ACL reconstruction using a BPTB graft. At a mean follow-up of 27xa0months, sagittal AP laxity was tested using a noninvasive knee measurement system (Genourob) with an applied pressure of 67xa0N, 89xa0N and 134xa0N. Rotational laxity was measured using a noninvasive rotational knee laxity device (Rotameter) with an applied torque of 5, 8 and 10xa0Nm. The results were compared with the measurements of the patients’ healthy contralateral knees. Tegner, Lysholm and IKDC score were used in order to evaluate the clinical outcome.ResultsPivot shift was negative (33) or glide (16) in 49 patients with 12 of 16 (75%) patients having also a pivot glide on the healthy contralateral side; Lachman tests were negative in 50 cases. Subjective assessment of the IKDC score was classified according to category A in 44 patients, B in 5 patients and C in 3 patients. Mean Lysholm score was 94.5xa0±xa09.5, median Tegner score was 7 (3–9) preoperative and 6 (3–9) at follow-up (n.s.). Anteroposterior knee laxity measurements revealed mean side-to-side differences of 0.6–1.3xa0mm (Pxa0<xa00.0001). Rotational laxity measurements revealed no statistical significant differences between the operated and the contralateral knee (n.s.). The measured differences in the entire rotational range varied from 0.2° to 1° depending on the applied torque. In those 3 patients with a positive pivot shift, differences in the entire rotational range of 4.5° at 5xa0N, 4.6° at 8xa0N and 4.1° at 10xa0N were found.ConclusionStatic knee laxity was quantified after ACL surgery using the introduced noninvasive measurement systems by comparing the measured results of the operated with the contralateral healthy knees. Significant differences were found in AP laxity although they were defined as clinically successful according to the IKDC classification. No significant differences were found in rotational knee laxity measurements. Therefore, the used noninvasive masurement devices might offer a high potential for objective quality control in knee ligament injuries and their treatment.Level of evidenceRetrospective case series, Level IV.

Midterm follow-up after implantation of a polyurethane meniscal scaffold for segmental medial meniscus loss: maintenance of good clinical and MRI outcome.

AbstractPurposenThe preservation of meniscal structure and function after segmental meniscal loss is of crucial importance to prevent early development of osteoarthritis. Implantation of artificial meniscal implants has been reported as a feasible treatment option. The purpose of this study was to assess the clinical and magnetic resonance imaging (MRI) results 4xa0years after implantation of a polyurethane scaffold for chronic segmental medial meniscus deficiency following partial medial meniscectomy.nMethodsEighteen patients received arthroscopic implantation of an Actifit® polyurethane meniscal implant (Orteq Sports Medicine, London, UK) for deficiency of the medial meniscus. Patients were followed at 6, 12, 24, and 48xa0months. Clinical outcome was assessed using established patient-reported outcome scores (KOOS, KSS, UCLA Activity Scale, VAS for pain). Radiological outcome was quantified by MRI scans after 6, 12, 24, and 48xa0months evaluating scaffold morphology, tissue integration, and status of the articular cartilage as well as signs of inflammation.nResultsMedian patient age was 32.5xa0years (range 17–49xa0years) with a median meniscal defect size of 44.5xa0mm (range 35–62xa0mm). Continuing improvement of the VAS and KSS Knee and Function Scores could be observed after 48xa0months compared to baseline, whereas improvement of the activity level according to UCLA continued only up to 24xa0months and decreased from there on. The KOOS Score showed significant improvement in all dimensions. MRI scans showed reappearance of bone bruises in two patients with scaffold extrusion. No significant changes in the articular cartilage could be perceived.ConclusionArthroscopic treatment for patients with chronic segmental meniscal loss using a polyurethane meniscal implant can achieve sustainable midterm results regarding pain reduction and knee function.Level of evidenceIV.

Advances in biology and mechanics of rotator cuff repair

AbstractHigh initial fixation strength, mechanical stability and biological healing of the tendon-to-bone interface are the main goals after rotator cuff repair surgery. Advances in the understanding of rotator cuff biology and biomechanics as well as improvements in surgical techniques have led to the development of new strategies that may allow a tendon-to-bone interface healing process, rather than the formation of a fibrovascular scar tissue. Although single-row repair remains the most cost-effective technique to address a rotator cuff tear, some biological intervention has been recently introduced to improve tissue healing and clinical outcome of rotator cuff repair. Animal models are critical to ensure safety and efficacy of new treatment strategies; however, although rat shoulders as well as sheep and goats are considered the most appropriate models for studying rotator cuff pathology, no one of them can fully reproduce the human condition. Emerging therapies involve growth factors, stem cells and tissue engineering. Experimental application of growth factors and platelet-rich plasma demonstrated promising results, but has not yet been transferred into standardized clinical practice. Although preclinical animal studies showed promising results on the efficacy of enhanced biological approaches, application of these techniques in human rotator cuff repairs is still very limited. Randomized controlled clinical trials and post-marketing surveillance are needed to clearly prove the clinical efficacy and define proper indications for the use of combined biological approaches.n The following review article outlines the state of the art of rotator cuff repair and the use of growth factors, scaffolds and stem cells therapy, providing future directions to improve tendon healing after rotator cuff repair.n Level of evidence Expert opinion, Level V.

Results of Surgical Treatment of Chronic Patellar Tendinosis (Jumper's Knee): A Systematic Review of the Literature

PURPOSEnTo review the literature concerning surgical treatment options for chronic patellar tendinosis (jumpers knee),xa0axa0common problem among athletes. When conservative treatment fails, surgical treatment is required.nnnMETHODSnSystematic review of the literature concerning the results of current surgical treatment options for chronic patellar tendinosis. All articles of studies with an evidence level ≥IV from January 2000 until February 2015 presenting the surgical outcome after arthroscopic as well as open treatment of chronic patellar tendinosis were included. The literature research of the PubMed database was performed using the following key words: patellar and tendinitis, tendonitis, tendinosis or tendinopathy; inferior patellar pole; jumpers knee; surgical treatment and open or arthroscopic patellar tenotomy.nnnRESULTSnA systematic review of the literature was performed especially to point out the effectiveness of arthroscopic treatment of chronic patellar tendinosis. The results revealed good clinical results for arthroscopic as well as open treatment of chronic patellar tendinosis that is refractory to conservative treatment in athletes. An average success rate of 87% was found for the open treatment group and of 91% for the arthroscopic treatment group. However, after open surgery, the mean time of return to the preinjury level of activity is 8 to 12 months, with a certain number of patients/athletes who cannot return to the preinjury level of activity.nnnCONCLUSIONSnMinimally invasive, arthroscopically assisted or all-arthroscopic procedures may lead to a significantly faster return to sporting activities and may, therefore, be the preferred method of surgical treatment.nnnLEVEL OF EVIDENCEnLevel IV, systematic review of Level I-IV studies.

Rotator cuff: biology and current arthroscopic techniques.

AbstractThe present article summarizes current trends in arthroscopic rotator cuff repairs focusing on the used repair technique, potential influencing factors on the results, and long-term outcome after reconstruction of the rotator cuff. Moreover, different treatment options for the treatment for irreparable rotator cuff ruptures were described, and the results of additional augmentation of the repairs with platelet-rich plasma were critically analyzed. Based on the current literature, double-row repairs did not achieve superior clinical results compared to single-row repairs neither in the clinical results nor in the re-rupture rate. Multiple factors such as age, fatty infiltration, and initial rupture size might influence the results. If the rupture is not repairable, various options were described including cuff debridement, partial repair, tuberoplasty, or tendon transfers. The additional augmentation with platelet-rich plasma did not reveal any significant differences in the healing rate compared to conventional rotator cuff repairs.n Level of evidence IV.