Thomas Stein

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.

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.

Tibiofemoral and patellofemoral joint 3D-kinematics in patients with posterior cruciate ligament deficiency compared to healthy volunteers

BackgroundThe posterior cruciate ligament (PCL) plays an important role in maintaining physiological kinematics and function of the knee joint. To date mainly in-vitro models or combined magnetic resonance and fluoroscopic systems have been used for quantifying the importance of the PCL. We hypothesized, that both tibiofemoral and patellofemoral kinematic patterns are changed in PCL-deficient knees, which is increased by isometric muscle flexion. Therefore the aim of this study was to simultaneously investigate tibiofemoral and patellofemoral 3D kinematics in patients suffering from PCL deficiency during different knee flexion angles and under neuromuscular activation.MethodsWe enrolled 12 patients with isolated PCL-insufficiency as well as 20 healthy volunteers. Sagittal MR-images of the knee joint were acquired in different positions of the knee joint (0°, 30°, 90° flexion, with and without flexing isometric muscle activity) on a 0.2 Tesla open MR-scanner. After segmentation of the patella, femur and tibia local coordinate systems were established to define the spatial position of these structures in relation to each other.ResultsAt full extension and 30° flexion no significant difference was observed in PCL-deficient knee joints neither for tibiofemoral nor for patellofemoral kinematics. At 90° flexion the femur of PCL-deficient patients was positioned significantly more anteriorly in relation to the tibia and both, the patellar tilt and the patellar shift to the lateral side, significantly increased compared to healthy knee joints. While no significant effect of isometric flexing muscle activity was observed in healthy individuals, in PCL-deficient knee joints an increased paradoxical anterior translation of the femur was observed at 90° flexion compared to the status of muscle relaxation.ConclusionsSignificant changes in tibiofemoral and patellofemoral joint kinematics occur in patients with isolated PCL-insufficiency above 30 degrees of flexion compared to healthy volunteers. Since this could be one reasonable mechanism in the development of osteoarthritis (OA) our results might help to understand the long-term development of tibiofemoral and/or patellofemoral OA in PCL-insufficient knee joints.

Extracorporeal shock wave therapy for non-calcific supraspinatus tendinitis – 10-year follow-up of a randomized placebo-controlled trial

Abstract Evidence for the efficacy of extracorporeal shock wave therapy (ESWT) in supraspinatus tendinopathy without calcification is sparse, and therefore this treatment option is often controversial. Patients of a randomized placebo-controlled study to analyze the effects of ESWT on function and pain were revisited 10 years after the initial consultation. The former verum group received 6000 impulses (energy flux density, 0.11 mJ/mm2) in three sessions after local anesthesia between 1999 and 2000. The placebo group had 6000 impulses of a sham ESWT after local anesthesia in the same period. Re-evaluation of the patients included a relative Constant score as well as pain measurements (visual analogue scale) during activity and at rest. No significant changes (p>0.05) in relative Constant scores, pain at rest, or pain during activity could be found after a 10-year follow-up between the placebo and verum groups after ESWT. The treatment of non-calcific supraspinatus tendinopathy with ESWT does not seem to have an effect on function or pain improvement in the long run. The results of the present study cannot advise the use of ESWT in cases of non-calcific supraspinatus tendinopathy.

Anatomic dissection of the anterolateral ligament (ALL) in paired fresh-frozen cadaveric knee joints

IntroductionDifferent dissection studies as well as comparative studies about the anterolateral ligament of the knee (ALL) already exist and the structure’s topology and properties have been shown. However, most of the studies investigating the ligament were performed in embalmed knees, which is thought to change the structural integrity of ligaments and thus the topologic and dynamic measurements. Since the biomechanical function of the ALL is not fully understood until today and a correlation with the pivot shift phenomenon is yet speculative, further studies will have to clarify its definitive importance. Its function as a limiter of internal rotation and lateral meniscal extrusion leads to the assumption of a secondary knee stabilizer.MethodsTwenty paired fresh-frozen cadaveric knees of ten donors have been dissected in a layerwise fashion. After identification of the ALL, topologic measurements were undertaken using a digital caliper.ResultsThe ALL could be identified as a tender, pearly structure in front of the anterolateral joint capsule in only 60% of the dissected knee joints. Only 20% of donors had a bilateral ALL while 80% had an ALL only in one side. Mean length, thickness and width as well as topographic measurements were comparable to other available studies investigating fresh-frozen cadavers.ConclusionAnatomy and topography of the ALL seem to be highly variable, but consistent within certain borders. Prevalence has to be argued though as it strongly differs between studies. The impact of an ALL absence, even if only unilateral, needs to be investigated in clinical and imaging studies to finally clarify its importance.

Stabilization of Acute High-Grade Acromioclavicular Joint Separation: A Prospective Assessment of the Clavicular Hook Plate Versus the Double Double-Button Suture Procedure:

Background: The stabilization strategy for acute high-grade acromioclavicular (AC) joint separations with AC-stabilizing clavicular hook plate (cHP) or coracoclavicular (CC)–stabilizing double double-button suture (dDBS) is still under consideration. Hypothesis: The CC-stabilizing dDBS is superior to the cHP according to an AC-specific radiologic assessment and score system. Study Design: Cohort study; Level of evidence, 2. Methods: Seventy-three consecutive patients with acute high-grade AC joint separation were prospectively followed in 2 treatment groups (64.4% randomized, 35.6% patient-selected treatment): open reduction and cHP (cHP group) or arthroscopically assisted dDBS (dDBS group) performed within 14 days of injury. Patients were prospectively analyzed by clinical scores (Taft, Constant score [CS], numeric analog scale for pain) and AC-specific radiographs (AC distance, CC distance [CCD], relative CCD [rCCD; 100 / AC distance × CCD]) at points of examination (preoperative and 6, 12, and 24 months). The minimal clinically important differences (MCIDs) were assessed by the anchor-based method. Results: Twenty-seven of 35 patients (mean age ± SD: 37.7 ± 9.7 years) after cHP implantation and 29 of 38 patients (34.2 ± 9.7 years) after dDBS implantation were continuously followed until the 24-month follow-up. All patients showed significantly increased scores after surgery as compared with preoperative status (all P < .05). As compared with GI, GII had significantly better outcomes at 24 months (Taft: cHP = 9.4 ± 1.7 vs dDBS = 10.9 ± 1.1, P < .05, MCID = 2.9; CS: cHP = 90.2 ± 7.8 vs dDBS = 95.3 ± 4.4, P < .02, MCID = 16.6) and at 24 months for Rockwood IV/V (Taft: cHP = 9.4 ± 1.7 vs dDBS = 11.1 ± 0.8, P < .0005; CS: cHP = 90.1 ± 7.7 vs dDBS = 95.5 ± 3.1, P < .04). Clinically assessed horizontal instability persisted in 18.52% (GI) and 6.89% (GII; P = .24). The rCCD showed equal loss of reduction at 24 months (GII = 130.7% [control = 111%] vs GI = 141.8% [control = 115%], MCID = 11.1%). Conclusion: This prospective study showed significantly superior outcomes in all clinical scores between GII and GI. The subanalysis of the high-grade injury type (Rockwood IV/V) revealed that these patients showed significant benefits from the dDBS procedure in the clinical assessments. The cHP procedure resulted in good to excellent clinical outcome data and displayed an alternative procedure for patients needing less restrictive rehabilitation protocols.

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.

Back to Sports After Arthroscopic Revision Bankart Repair

Background: Recurrent instability following primary arthroscopic stabilization of the shoulder is a common complication. Young, athletic patients are at the greatest risk of recurring instability. To date, the literature contains insufficient description regarding whether return to sports is possible after revision arthroscopic Bankart repair. Hypothesis: Patients presenting with recurrent instability after primary arthroscopic stabilization should expect limitations in terms of their ability to partake in sporting activities after revision surgery. Study Design: Case series; Level of evidence, 4. Methods: Twenty athletes who underwent arthroscopic revision stabilization of the shoulder after failed primary arthroscopic Bankart repair were included in the study after completing inclusion and exclusion criteria surveys. Athletic Shoulder Outcome Scoring System (ASOSS), Shoulder Sport Activity Score (SSAS), and the Subjective Patient Outcome for Return to Sports (SPORTS) scores were determined to assess the participants’ ability to partake in sporting activities. Furthermore, sport type and sport level were classified and recorded. To assess function and stability, Rowe, American Shoulder and Elbow Surgeons, Constant-Murley, and Walch-Duplay scores were measured and recorded. Results: Follow-up consultations were carried out after a mean of 28.7 months. The mean age at follow-up examination was 27.75 years. At the time of follow-up, 70% of the patients were able to return to their original sporting activities at the same level. However, 90% of patients described a limitation in their shoulder when participating in their sports. At 28.7 months after surgery, the mean ASOSS score was 76.8; the SSAS score decreased from 7.85 before first-time dislocation to 5.35 at follow-up (P < .005). The SPORTS score was 5.2 out of 10 at the follow-up consultation. Function- and instability-specific scores showed good to excellent results. The mean external rotational deficit for high external rotation was 9.25°, and for low external rotation it was 12°. Conclusion: Patients can return to their original type and level of sport after arthroscopic revision Bankart repair, but they must expect persistent deficits and limitations to the shoulder when put under the strains of sporting activity. Patients with shoulder injuries who partake in sports that put greater demand on the shoulder show the smallest probabilities of returning to sporting activity.

Lower complication rate and faster return to sports in patients with acute syndesmotic rupture treated with a new knotless suture button device

PurposeSuture button devices for tibiofibular syndesmosis injuries provide semirigid dynamic stabilization, but complications including knot irritation have been reported. No randomized trials of the new knotless suture button devices have been performed. We hypothesized that knotless suture button devices eliminate knot irritation and facilitate quicker return to sports. This study was performed to compare the clinical outcomes, complication rates, and time to return to sports between a new knotless suture button device and syndesmotic screw fixation.MethodsThis study included 54 patients treated for ankle syndesmotic injury from 2012 to 2014 with a knotless suture button device or syndesmotic screw fixation. Clinical outcomes were measured using the American Orthopaedics Foot and Ankle Society score, Foot and Ankle Disability Index, Olerud and Molander score, and visual analog scale for pain and function. Secondary outcome measures were the complication rate and time required to return to sports. Patients underwent clinical and radiological evaluations preoperatively and three times during the 1-year postoperative follow-up.Results54 of 62 eligible patients were analyzed, median age 37 (18–60) and underwent the 1-year follow-up. The screw fixation and knotless suture button groups comprised 26 and 28 patients, respectively. The complication rate was significantly lower (p = 0.03) and time to return to sports was significantly shorter in the knotless suture button than screw fixation group (average, 14 versus 19 weeks, respectively; p = 0.006). No significant differences were identified in clinical outcomes or visual analog scale scores for pain and function between the groups. Age, injury mechanism, and body mass index did not significantly affect the time required to return to sports activities. The type of fixation was the only independent variable that reached statistical significance (p = 0.006).ConclusionSyndesmotic screw fixation and the new knotless suture button device both resulted in good clinical results. Lower complication rate and the earlier time to return to sports make the new knotless suture button device recommendable especially for highly active patients.Level of evidenceRandomized controlled trial, Level I.

Medial patellofemoral ligament reconstruction fails to correct mild patella alta in cases of patellofemoral instability—a case-control study

PurposeMedial patellofemoral ligament reconstruction (MPFL-R) is the gold standard in patella soft tissue surgery for patellofemoral instability. Although claimed, recent reports indicate that MPFL-R may fail to distalize the patella in mild cases of patella alta. The present study is a retrospective case-control study to compare radiographic patella height between MPFL-R and historical Insall’s proximal realignment (IPR) pre- and post-operatively with respect to distalization and assess redislocation rates at a mid-term follow-up.MethodsSixty-four patients were age/sex matched (1:1), yielding 32 patients for group 1 MPFL-R (cases) and 32 patients for group 2 IPR (controls). Insall-Salvati, Blackburne-Peel and Caton-Deschamps indices were analyzed for differences pre- and post-operatively. An additional inter-rater reliability analysis was performed by means of intra-class correlation (ICC). Redislocation rates were considered as treatment failures in this study.ResultsICC was excellent for all three patella indices. MPFL-R failed to show significant differences if compared to IPR with respect to distalization in mild stages of patella alta. Moreover, redislocation rates significantly favored MPFL-R (3.1%) over IPR (12.5%; p < 0.0001).ConclusionsMPFL-R has become a popular option to restore native patellofemoral biomechanics after ligament rupture. However, the procedure’s potential to correct concomitant patella alta should not be overestimated and indications considered carefully.