Peter Ueblacker

Terminology and classification of muscle injuries in sport: The Munich consensus statement

Objective To provide a clear terminology and classification of muscle injuries in order to facilitate effective communication among medical practitioners and development of systematic treatment strategies. Methods Thirty native English-speaking scientists and team doctors of national and first division professional sports teams were asked to complete a questionnaire on muscle injuries to evaluate the currently used terminology of athletic muscle injury. In addition, a consensus meeting of international sports medicine experts was established to develop practical and scientific definitions of muscle injuries as well as a new and comprehensive classification system. Results The response rate of the survey was 63%. The responses confirmed the marked variability in the use of the terminology relating to muscle injury, with the most obvious inconsistencies for the term strain. In the consensus meeting, practical and systematic terms were defined and established. In addition, a new comprehensive classification system was developed, which differentiates between four types: functional muscle disorders (type 1: overexertion-related and type 2: neuromuscular muscle disorders) describing disorders without macroscopic evidence of fibre tear and structural muscle injuries (type 3: partial tears and type 4: (sub)total tears/tendinous avulsions) with macroscopic evidence of fibre tear, that is, structural damage. Subclassifications are presented for each type. Conclusions A consistent English terminology as well as a comprehensive classification system for athletic muscle injuries which is proven in the daily practice are presented. This will help to improve clarity of communication for diagnostic and therapeutic purposes and can serve as the basis for future comparative studies to address the continued lack of systematic information on muscle injuries in the literature. What are the new things Consensus definitions of the terminology which is used in the field of muscle injuries as well as a new comprehensive classification system which clearly defines types of athletic muscle injuries. Level of evidence Expert opinion, Level V.

Osteochondral transplantation to treat osteochondral lesions in the elbow

BACKGROUND Effective treatment of osteochondral lesions in the elbow remains challenging. Arthroscopic débridement and microfracture or retrograde drilling techniques are often insufficient and provide only temporary symptomatic relief. The purpose of this study was to evaluate the treatment of these lesions with osteochondral autografts. METHODS From 1999 to 2002, seven patients with osteochondral lesions of the capitellum humeri (five patients), trochlea (one patient), or radial head (one patient) were treated with cylindrical osteochondral grafts, which were harvested from the non-weight-bearing area of the proximal aspect of the lateral femoral condyle. The patients (three female and four male patients with an average age of seventeen years) were evaluated preoperatively and postoperatively, with an average follow-up of fifty-nine months. The Broberg and Morrey score was chosen for functional evaluation of the elbow (with regard to motion, pain, strength, activities of daily living, and stability), and the American Shoulder and Elbow Surgeons score was used for the analysis of pain. All patients had imaging studies done preoperatively to evaluate the defect and postoperatively to assess the ingrowth and viability of the graft. The ipsilateral knee was examined for donor-site morbidity. RESULTS The Broberg and Morrey score improved from a mean (and standard deviation) of 76.3 +/- 13.2 preoperatively to 97.6 +/- 2.7 postoperatively, and pain scores were significantly reduced (p < 0.05). The mean elbow extension lag of 4.7 degrees +/- 5.8 degrees was reduced to 0 degrees postoperatively. Compared with the contralateral side, there was a mean preoperative flexion lag of 12.9 degrees +/- 13.8 degrees . At the time of the final follow-up, flexion was free and was equal bilaterally in all patients. None of the plain radiographs made at the time of follow-up showed any degenerative changes or signs of osteoarthritis. The postoperative magnetic resonance imaging scans showed graft viability and a congruent chondral surface in all seven patients. No donor-site morbidity was noted at one year postoperatively. CONCLUSIONS The osteochondral autograft procedure described in the present study provides the opportunity to retain viable hyaline cartilage for the repair of osteochondral lesions in the elbow while restoring joint congruity and function and perhaps reducing the risk of osteoarthritis. These medium-term results suggest that the risks of a two-joint procedure are modest and justifiable. In addition, the described technique provides an option for revision surgery after the failure of other surgical procedures.

The influence of the stable expression of BMP2 in fibrin clots on the remodelling and repair of osteochondral defects.

Growth factors like BMP2 have been tested for osteochondral repair, but transfer methods used until now were insufficient. Therefore, the aim of this study was to analyse if stable BMP2 expression after retroviral vector (Bullet) transduction is able to regenerate osteochondral defects in rabbits. Fibrin clots colonized by control or BMP2-transduced chondrocytes were generated for in vitro experiments and implantation into standardized corresponding osteochondral defects (n=32) in the rabbit trochlea. After 4 and 12 weeks repair tissue was analysed by histology (HE, alcian-blue, toluidine-blue), immunohistochemistry (Col1, Col2, aggrecan, aggrecan-link protein), ELISA (BMP2), and quantitative RT-PCR (BMP2, Col1, Col2, Col10, Cbfa1, Sox9). In vitro clots were also analysed by BMP2-ELISA, histology (alcian-blue), quantitative RT-PCR and in addition by electron microscopy. BMP2 increased Col2 expression, proteoglycan production and cell size in vitro. BMP2 transduction by Bullet was efficient and gene expression was stable in vivo over at least 12 weeks. Proteoglycan content and ICRS-score of repair tissue were improved by BMP2 after 4 and 12 weeks and Col2 expression after 4 weeks compared to controls. However, in spite of stable BMP2 expression, a complete repair of osteochondral defects could not be demonstrated. Therefore, BMP2 is not suitable to regenerate osteochondral lesions completely.

Antegrade nailing of humeral head fractures with captured interlocking screws.

Objectives/Design: To assess the functional outcome after treatment of proximal humeral fractures with a new antegrade nail that provides angular and sliding stability. Intervention/Patients: Ninety-seven patients were treated during a 4-year period between April 2000 and March 2004. All patients were followed for 6 months, 51 patients (53%) for 12 months, and 31 patients (32%) for 24 months. This study focuses mainly on the patients with a follow up of 1 year. Their mean age was 68 years (range: 33 to 90); 22% were more than 80 years of age. Main Outcome Measurements: All fractures were radiologically graded by the Neer and AO/ASIF classifications. Clinical assessment was performed at all follow-up visits using the Constant-Murley and Neer scores, and complications were recorded. Results: There were 26.8% 2-part, 66% 3-part, and 7.2% 4-part fractures. The relative Constant-Murley score improved significantly (P < 0.001) from 72% at 6 months to 82% at 12 months after operation. No further improvement regarding functional outcome was observed after 24 months. Patients younger than 60 years of age had better results. No significant functional differences were found among 2-, 3- or 4-part fractures. Complications included backing out of the proximal screws (9.8%), secondary dislocation (1.9%), complete osteonecrosis (1.9%), and partial osteonecrosis (5.8%). Conclusion: Treatment with this nail provides sufficient fixation of the fragments to allow early mobilization. The good functional results in the majority of the patients indicate that this nail can be used, even in complex fractures and elderly patients.

Epidemiological and clinical outcome comparison of indirect (‘strain’) versus direct (‘contusion’) anterior and posterior thigh muscle injuries in male elite football players: UEFA Elite League study of 2287 thigh injuries (2001–2013)

Background Data regarding direct athletic muscle injuries (caused by a direct blunt or sharp external force) compared to indirect ones (without the influence of a direct external trauma) are missing in the current literature—this distinction has clinical implications. Aim To compare incidence, duration of absence and characteristics of indirect and direct anterior (quadriceps) and posterior thigh (hamstring) muscle injuries. Methods 30 football teams and 1981 players were followed prospectively from 2001 until 2013. The team medical staff recorded individual player exposure and time-loss injuries. Muscle injuries were defined as indirect or direct according to their injury mechanism. Results In total, 2287 thigh muscle injuries were found, representing 25% of all injuries. Two thousand and three were valid for further analysis, of which 88% were indirect and 12% direct. The incidence was eight times higher for indirect injuries (1.48/1000 h) compared to direct muscle injuries (0.19/1000 h) (p<0.01). Indirect muscle injuries caused 19% of total absence, and direct injuries 1%. The mean lay-off time for indirect injuries amounted to 18.5 days and differed significantly from direct injuries which accounted for 7 days (p<0.001). 60% of indirect injuries and 76% of direct injuries occurred in match situations. Foul play was involved in 7% of all thigh muscle injuries, as well as in 2% of indirect injuries and 42% of direct injuries. Summary Muscle anterior and posterior thigh injuries in elite football are more frequent than have been previously described. Direct injuries causing time loss are less frequent than indirect ones, and players can usually return to full activity in under half the average time for an indirect injury. Foul play is involved in 7.5% of all thigh muscle injuries.

Intravenous bisphosphonates and vitamin D in the treatment of bone marrow oedema in professional athletes

INTRODUCTION The goal of this retrospective study was to evaluate the safety and efficacy of ibandronate for bone marrow oedema (BMO) syndrome and stress fracture cases, and to demonstrate an additional field of therapeutic importance-the high-performance athlete. PATIENTS AND METHODS This retrospective study included twenty-five high-performance athletes. Sixty per cent of the athletes were European soccer players and 40.0% other high-class international athletes (3 women and 22 men with an average age of 25.0±4.2), with BMO of the lower trunk or extremity diagnosed by magnetic resonance imaging (MRI). The treatment regimen consisted of high-dose vitamin D supplementation and intravenous ibandronate therapy. RESULTS The time between the onset of pain and proper diagnosis of BMO was 106.3±104.1 days. Excellent pain reduction (pain at rest and under strain) and improved mobility was reported within the first two weeks after the first ibandronate administration by sixteen patients (64%). The time from first treatment until return to competition (RTC) was on average 102.6±65.2 days in total. If the time from onset of pain until diagnosis was within 40 days, the RTC was significantly reduced (p≤0.05) to almost 50% (63.8±48.1 days) when compared to the athletes with later diagnosis (124.4±63.2 days). CONCLUSIONS The here-applied therapy regimen of intravenous BPs application and vitamin D supplementation in BMO syndrome has a beneficial effect for high-performance athletes. An early diagnosis and rapid treatment start can reduce the RTC significantly. An optimal bone metabolism with sufficient daily calcium and vitamin D intake is crucial and should not only be strived for the professional but also for the recreational athlete.

Treatment of muscle injuries in football

ABSTRACT Muscle injuries are frequent and represent one of the most substantial medical problems in professional football. They can have both traumatic and overuse causes with direct practical consequence due to differences in terms of the post-primary care regimen and prognosis. An accurate diagnosis is the first step towards a specific treatment and usually allows to predict return to play (RTP). Current treatment principles have no firm scientific basis; they are practiced largely as empirical medicine due to a lack of prospective randomised studies. Immediate treatment usually follows the PRICE-principle (protection, rest, ice, compression, elevation). Depending on the type of the muscle injury, specific physical and physiotherapeutical procedures as well as rehabilitative exercises and gradual training therapy are used to recondition the injured structure, to restore coordination and proprioception, and to normalise movement patterns. Injection therapy with various substances is frequently used, with positive results empirically, but evidence in form of prospective randomised studies is lacking. A precise rehabilitation plan should be developed for every muscle injury, including recommendations for sport-specific training with increasing intensity. Since there are no guidelines regarding safe RTP, regular follow-up examinations on the current muscle status are crucial to evaluate the progress made in terms of healing and to determine when the injured muscle can be exposed to the next step of load. This narrative review describes the various factors that a medical team should consider during assessment, treatment and rehabilitation of a muscle injury with particular focus on professional football.

Deterioration of teeth and alveolar bone loss due to chronic environmental high-level fluoride and low calcium exposure

ObjectivesHealth risks due to chronic exposure to highly fluoridated groundwater could be underestimated because fluoride might not only influence the teeth in an aesthetic manner but also seems to led to dentoalveolar structure changes. Therefore, we studied the tooth and alveolar bone structures of Dorper sheep chronically exposed to very highly fluoridated and low calcium groundwater in the Kalahari Desert in comparison to controls consuming groundwater with low fluoride and normal calcium levels within the World Health Organization (WHO) recommended range.Materials and methodsTwo flocks of Dorper ewes in Namibia were studied. Chemical analyses of water, blood and urine were performed. Mineralized tissue investigations included radiography, HR-pQCT analyses, histomorphometry, energy-dispersive X-ray spectroscopy and X-ray diffraction-analyses.ResultsFluoride levels were significantly elevated in water, blood and urine samples in the Kalahari group compared to the low fluoride control samples. In addition to high fluoride, low calcium levels were detected in the Kalahari water. Tooth height and mandibular bone quality were significantly decreased in sheep, exposed to very high levels of fluoride and low levels of calcium in drinking water. Particularly, bone volume and cortical thickness of the mandibular bone were significantly reduced in these sheep.ConclusionsThe current study suggests that chronic environmental fluoride exposure with levels above the recommended limits in combination with low calcium uptake can cause significant attrition of teeth and a significant impaired mandibular bone quality.Clinical relevanceIn the presence of high fluoride and low calcium-associated dental changes, deterioration of the mandibular bone and a potential alveolar bone loss needs to be considered regardless whether other signs of systemic skeletal fluorosis are observed or not.

Knorpel aus dem Labor — eine Sackgasse?

ZusammenfassungKnorpeldefekte sind bei jüngeren und aktiven Patienten für erhebliche Funktionseinschränkungen am Bewegungs- und Stützorgan verantwortlich. Mechanismen für eine Spontanheilung existieren nicht. Aktuelle biologische Therapieansätze reparieren durch lokale Regeneration oder Umsetzung von Gelenkflächenstanzen mit begrenztem Erfolg. Zell- und Gewebekulturtechniken (Tissue Engineering) ermöglichen die Produktion von Gelenkflächenimplantaten aus körpereigenen Zellen, wie hier an einem Tiermodell dokumentiert. Der gesamte Prozess der Zellvermehrung und der Knorpelgewebebildung findet im Bioreaktor statt. Die Einjahresergebnisse bestätigen den Erfolg von Knorpel aus dem Labor. Ob sich das Tissue Engineering als Therapie durchsetzen wird, hängt neben dem weiteren Forschungsaufwand aber auch von gesundheitspolitischen Bedingungen ab. Würde das Verfahren trotz medizinischer Notwendigkeit am Markt nicht realisiert, werden die Kenntnisse, die bei seiner Entwicklung gewonnen wurden, die lokale In-situ-Regeneraion ermöglichen, wobei das Gelenk selber als Bioreaktor des Tissue Engineering dient, wenn hindernde Faktoren ausgeschaltet sind.AbstractCartilage defects are responsible in younger and active patients for substantial functional restrictions. Mechanisms for spontaneous healing do not exist. Current biological therapy concepts repair by local regeneration or transplantation of joint segments with limited success. Cell and tissue engineering techniques allow the production of joint surface implants from autologous cells, as documented in an animal model. The entire process of the proliferation and the cartilage tissue formation takes place in a bioreactor. The 1-year follow-up confirms the success of cartilage from the bioreactor. Whether tissue engineering will become generally accepted as therapy depends, apart from the still necessary research expenditure, on conditions of healthcare policy. If the procedure is not realized despite its medical usefulness in the market, the knowledge gained through its development will make local in situ regeneration possible, whereby the joint itself serves as a bioreactor for tissue engineering if preventing factors are eliminated.

Osteochondrale Transplantation@@@Osteochondral transplantation: Ein bewährtes Therapieverfahren für größere Knorpeldefekte an Knie und OSG@@@A reliable method for large cartilaginous defects of the knee and ankle

ZusammenfassungDie Aussage des englischen Chirurgen W. Hunter von 1743, dass Knorpelschäden sehr unangenehm sind, nie heilen und schwieriger zu behandeln sind als Knochenschäden, trifft auch heute noch zu. Es existiert nach wie vor kein allgemein und umfassend erfolgreiches Konzept, das zu einer vollständigen Ausheilung der Defekte mit uneingeschränkter Wiederaufnahme der sportlichen oder alltäglichen Betätigungen führt. Derzeit werden kleinere Defekte durch das Microfracture-Verfahren, größere Läsionen mittels Knorpel-Knochen-Transplantation behandelt, während bei diffusen Arthrosen gesamter Gelenke meist der radikale endoprothetische Oberflächenersatz bzw. bei jüngeren Patienten eher eine Arthrodese zum Einsatz kommen. Die autogene Knorpel-Knochen-Transplantation ist ein viel versprechendes Verfahren mit guten Resultaten, die u. a. darauf zurückzuführen sind, dass der Defekt durch Zylinder von hyalinem, gesundem Knorpel mit den idealtypischen histologischen und biomechanischen Eigenschaften des Originalknorpels ersetzt wird. Weitere Vorteile sind die im Vergleich zu anderen Verfahren der Knorpel-Knochen-Transplantation geringe Entnahmemorbidität sowie die sofort mögliche Mobilisierung und Vollbelastung. Zudem ist das Verfahren kostengünstig.AbstractThe statement made by the English surgeon W. Hunter in 1743 that“ulcerated cartilage is a very troublesome desease, its cure is more difficult than that of carious bone and when destroyed, it is never recovered” still applies to a great extent today. There is still no generally and comprehensively successful concept capable of producing complete healing of the damage with unrestricted resumption of sports or daily activities. Currently, small defects are treated using the microfracture method, larger lesions using osteochondral transplantation, while diffuse osteoarthritis of the whole joint usually require radical endoprosthetic resurfacing or, in younger patients, preferably arthrodesis. Autogenous cartilage-bone transplantation is a very promising technique with good results due to the fact that the defect is replaced by hyaline cylinders of healthy cartilage with the ideal histological and biomechanical characteristics of the native cartilage. Further advantages of the cartilage-bone transplantation method in comparison to other methods include low donor site morbidity, as well as immediate load-bearing and mobility. And the procedure is cost-saving.