Sandwich Technique for Large Osteochondral Lesions of the Knee.

OBJECTIVE: To evaluate whether a sandwich technique procedure for large osteochondral lesions (OCL) of the medial femur condyle reduces clinical symptoms and improves activity level as well as to assess repair tissue integration on MRI over 2 years. DESIGN: Twenty-one patients (median age: 29 years, 18-44 years) who received matrix-associated autologous chondrocyte transplantation (MACT) combined with cancellous bone grafting at the medial femur condyle in a 1-step procedure were prospectively included. Patients were evaluated before surgery (baseline) as well as 3, 6, 12, and 24 months postoperatively, including clinical evaluation, Lysholm score, Tegner Activity Rating Scale, and MRI with Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and a modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). RESULTS: Seventeen patients were available for the 24-month (final) follow-up (4 dropouts). Lysholm significantly improved from 48 preoperatively stepwise to 95 at final follow-up (P < 0.05). Tegner improvement from 2.5 at baseline to 4.0 at final follow-up was not significant (P = 1.0). MOCART score improved significantly and stepwise from 65 at 3 months to 90 at 24 months (P < 0.05). Total WORMS improved from 14.5 at surgery to 7.0 after 24 months (P < 0.05). Body mass index and defect size at surgery correlated with total WORMS at final follow-up (P < 0.05) but did not correlate with clinical scores or defect filling. CONCLUSION: MACT combined with cancellous bone grafting at the medial femoral condyle reduces symptoms continuously over 2 years. A 1-step procedure may reduce perioperative morbidity. However, despite improvements, patients' activity levels remain low, even 2 years after surgery.

Neither lateral patellar facet nor patellar size are altered in patellofemoral unstable patients: a comparative magnetic resonance imaging analysis.

PURPOSE: It remains unclear if morphologic patterns of the patella itself predispose to patellar instability. This study examined established patellar landmarks in relation to the femoral condyle width to clarify differences of patellar morphologies in patellofemoral stable and unstable patients. METHODS: Magnetic Resonance Imaging of 50 subjects (20.7 ± 4.4 years; 17 males, 33 females) with patellofemoral instability (study group, SG) and 50 subjects (25.3 ± 5.8 years; 31 males, 19 females) with anterior cruciate ligament rupture (control group, CG) were analyzed. Corresponding patellar value indices (PW-I; LPF-I 1; LPF-I 2) in relation to the femoral condyle width (FCW) were evaluated after the measurement of absolute patellar dimension [patellar width (PW); direct length of the lateral patellar facet (LPF-1); projected length of the lateral patellar facet (LPF-2)]. The patellar shape according to Wiberg, trochlear dysplasia, patellar height, and tibial tubercle-trochlear groove (TT-TG) distance were determined. RESULTS: The SG showed a significantly longer absolute (LPF 2) (P = 0.041) and relative (LPF-I 1, LPF-I 2) (P < 0.001) lateral facet of the patella. No significant differences were evaluable for the relative patellar width (PW-I) (ns). A patellar shape type 3 (P = 0.001) as well as a higher position of the patella and TT-TG-distance (P < 0.001) were significantly more often present in the SG. CONCLUSION: There are several bony alterations associated with patellofemoral instability, but our data did not show a significantly smaller lateral patellar facet or relative patellar width that could facilitate a patellar dislocation. This helps surgeons, that are considering to surgically address the patella in cases of patellofemoral instability, to better understand its morphologic pattern. LEVEL OF EVIDENCE: III.

Reduction of hospital stay at maternity unit: an evaluation of the impact on maternal and neonatal readmission.

In June 2015, the Belgian federal minister of public health imposed a reduction of 1 day in hospital stay at the maternity unit. This retrospective cohort study evaluated data of all patients who delivered between January 01 2010 and November 30 2015. Neonatal readmissions during the first 28 days postpartum and maternal readmissions during the first 6 weeks postpartum were studied. In total, 6009 births were included. The neonatal readmissions significantly increased (4.8% versus 6.9%, p value = .04) after June 2015. There was no significant difference in maternal readmissions between groups. In conclusion, hospital stay reduction at the maternity unit was linked with an increase of neonatal readmissions in the first 28 days postpartum, but did not have an effect on the maternal readmissions.Impact StatementWhat is already known on this subject? Many studies have evaluated the impact of early discharge on maternal and neonatal morbidity since 1950. Nevertheless, there are still concerns regarding the advantages and inconveniences of this policy. This retrospective cohort study took place in a tertiary referral centre in Belgium (CHU Tivoli) and evaluated data of all patients who delivered between January 01 2010 and November 30 2015.What the results of this study add? The readmissions for icterus increased significantly after the introduction of the reduced stay. There was no significant difference in maternal readmissions between groups.What the implications are of these findings for clinical practice and/or further research? A shorter hospital may be linked with an increase of neonatal readmissions in the first 28 days postpartum, but does not seem to have an effect on the maternal readmissions. Further prospective studies are needed in order to validate this hypothesis and also elucidate the reasons leading to a higher neonatal readmission rate.

The challenge of extra-intra craniometry: a computer-assisted three-dimensional approach on the equine skull.

BACKGROUND: The topographical correlations between certain extracranial and intracranial osseous points of interest (POIs), and their age-related changes, are indispensable to know for a diagnostical or surgical access to intracranial structures; however, they are difficult to assess with conventional devices. MATERIALS AND METHODS: In this pilot study, the 3-dimensional coordinates of extra-/intracranial POIs were determined, thus avoiding perspective distortions that used to be intrinsic problems in 2-dimensional morphometry. The data sets were then analysed by creating virtual triangles. The sizes, shapes, and positions of these triangles described the extent and the directions of the age-related shifts of the POIs. A selection of extracranial and intracranial POIs were marked on half skulls of four warmblood horses in two age groups (young: 6 weeks, n = 2; old: 14 and 17 years, n = 2). The x-, y-, and z-coordinates of these POIs were determined with a measurement arm (FaroArm Fusion, FARO Europe®). Direct distances between the POIs as well as their indirect distances on the x-, y-, and z-axis, and angles were calculated. RESULTS: The analysed virtual triangles revealed that some parts of the skull grew in size, but did not change in shape/relative proportions (proportional type of growth, as displayed by POI A and POI B at the Arcus zygomaticus). The same POIs (A and B) remained in a very stable relationship to their closest intracranial POI at the Basis cranii on the longitudinal axis, however, shifted markedly in the dorso-lateral direction. In contrast, a disproportional growth of other parts of the cranium was, for example, related to POI C at the Crista nuchae, which shifted strongly in the caudal direction with age. A topographically stable reference point (so-called anchor point) at the Basis cranii was difficult to determine. CONCLUSIONS: Two candidates (one at the Synchondrosis intersphenoidalis, another one at the Synchondrosis sphenooccipitalis) were relatively stable in their positions. However, the epicentre of (neuro-)cranial growth could only be pinpointed to an area between them.

Functional outcome after transphyseal anterior cruciate ligament reconstruction in young patients with open growth plates.

BACKGROUND: This study evaluates sports ability, rotational laxity and potential growth changes in children after transphyseal ACL reconstruction with metaphyseal fixation technique, considering physis biology by placing drill holes vertically in the femoral anatomic origin in order to reduce volumetric injury to the physis. METHODS: In this retrospective trial of 42 patients data were collected. Thirty-seven were reviewed measuring rotational laxity and anteroposterior tibial translation using the Laxitester (ORTEMA Sport Protection, Markgroeningen, Germany) and the KT1000. Clinical examination was evaluated with the IKDC 2000 knee examination form. Leg axis was determined with digital photography and leg length was assessed clinically. Sports ability was assessed with questionnaires including subjective IKDC, Tegner Activity Scale, Activity Rating Scale and a questionnaire on sports and level of sports. RESULTS: Mean follow-up was 24.9months. Mean age at surgery was 13.2years in boys and 13.1years in girls. IKDC 2000 grading was A or B in 28 patients and C in nine patients. Significant increased anterior tibial translation was observed in neutral position and in external tibia rotation. No growth abnormalities were seen. Fifty-seven percent of the patients were able to participate in competitive sports at follow-up. CONCLUSION: Transphyseal ACL reconstruction with metaphyseal fixation in children with open growth plates can be done with low risk of growth changes. Return to competitive sports is possible although low rotational laxity still exists. LEVEL OF EVIDENCE: IV.

Mid-term Functional Outcome and Return to Sports after Proximal Hamstring Tendon Repair.

Proximal hamstring tendon ruptures are commonly associated with a significant loss of function, and operative treatment is recommended in active patients. The objective was to evaluate objective/subjective functional results and return to sports following proximal hamstring tendon repair in the mid-term follow-up. 16 repairs of proximal hamstring ruptures were performed in 15 patients (9 males, 6 females). The average age at the time of injury was 47 years (range, 21-66). All patients were clinically examined at a mean follow-up of 56 months (range, 24-112 months). Validated patient-oriented assessment scores focussing on sports activity including the Lysholm Score, Tegner Activity Score, UCLA Activity Score, adapted WOMAC Score, and the VAS were evaluated as well as the return to sports. Isokinetic strength of both legs was tested using a rotational dynamometer. The Lysholm, Tegner, UCLA Activity Score and the adapted WOMAC demonstrated predominantly a return to a preinjury activity level at follow-up. Functional measurements of the operated leg showed similar results to the uninjured leg in knee extension and flexion strength (p>0.094). In return to sports, no signficant (p>0.05) differences concerning types or frequency were noted. The surgical repair of proximal hamstring tendon ruptures leads to constantly good functional results in the mid-term follow-up, where patients demonstrate similar isokinetic results in the healthy leg.

[Factors Associated with the Use of Protective Gear among Adults during Recreational Sledging]. / Einflussfaktoren auf das Tragen von Schutzausrüstung bei erwachsenen Rodlern.

BACKGROUND: Recreational sledging (tobogganing) is a very popular winter sport in the Alps. Therefore, injury prevention through the usage of protective gear seems important. Therefore, the aim of this study was to evaluate factors associated with the use of protective gear among adults during recreational sledging. METHODS: Adult recreational sledgers were interviewed during the winter seasons 2012/13 and 2013/14 at six sledging tracks in Austria on demographics, skill level, sledging frequency, risk taking behaviour, sitting alone or with another person on the sledge, previous sledging-related injuries, and use of protective gear, respectively. Interviews were conducted on all days of the week. RESULTS: A total of 1968 adult sledgers (49.4 % females) with a mean age of 37.1 ±â€Š14.4 years participated in this study. A (ski) helmet, sun or snow goggles, a back protector, and wrist guards were used by 42.3 %, 71.0 %, 5.9 %, 2.6 % of sledgers, respectively. Helmet use was significantly higher with increasing age and increasing skill level as well as when sitting alone compared to sitting together with another person. Females, Austrians, persons sitting alone on the sledge, a higher frequency of sledging and a higher skill level were significantly associated with an increasing use of goggles. A back protector was significantly more often worn by younger people, more risky sledgers, and persons with a previous sledging-related injury. Wrist guards were significantly more often used by persons with a previous sledging-related injury. CONCLUSION: During recreational sledging, the factors age, sex, nationality, skill level, sitting alone compared to sitting together with another person on the sledge, sledging frequency, and injury experience were associated with the frequencies of usage of different types of protective gear. These factors should be considered when implementing preventive measures for recreational sledging.

Bilateral cartilage T2 mapping 9 years after Mega-OATS implantation at the knee: a quantitative 3T MRI study.

OBJECTIVE: To evaluate morphological and quantitative MR findings 9 years after autograft transfer of the posterior femoral condyle (Mega-OATS) and to correlate these findings with clinical outcomes. Quantitative MR measurements were also obtained of the contralateral knee and the utility as reference standard was investigated. DESIGN: Both knees of 20 patients with Mega-OATS osteochondral repair at the medial femoral condyle (MFC) were studied using 3T MRI 9 years after the procedure. MR-sequences included morphological sequences and a 2D multislice multiecho (MSME) spin echo (SE) sequence for quantitative cartilage T2 mapping. Cartilage segmentation was performed at the cartilage repair site and six additional knee compartments. Semi-quantitative MR observation of cartilage repair tissue (MOCART) scores and clinical Lysholm scores were obtained. Paired t-tests and Spearman correlations were used for statistical analysis. RESULTS: Global T2-values were significantly higher at ipsilateral knees compared to contralateral knees (42.1 ± 3.0 ms vs 40.4 ± 2.6 ms, P = 0.018). T2-values of the Mega-OATS site correlated significantly with MOCART scores (R = -0.64, P = 0.006). The correlations between MOCART and Lysholm scores and between absolute T2-values and Lysholm scores were not significant (P > 0.05). However, higher T2 side-to-side differences at the femoral condyles correlated significantly with more severe clinical symptoms (medial, R = -0.53, P = 0.030; lateral, R = -0.51, P = 0.038). CONCLUSIONS: Despite long-term survival, 9 years after Mega-OATS procedures, T2-values of the grafts were increased compared to contralateral knees. Clinical scores correlated best with T2 side-to-side differences of the femoral condyles, indicating that intraindividual adjustment may be beneficial for outcome evaluation.

FOLFOX4 versus sequential dose-dense FOLFOX7 followed by FOLFIRI in patients with resectable metastatic colorectal cancer (MIROX): a pragmatic approach to chemotherapy timing with perioperative or postoperative chemotherapy from an open-label, randomized phase III trial.

BACKGROUND: Perioperative FOLFOX4 (oxaliplatin plus 5-fluorouracil/leucovorin) chemotherapy is the current standard in patients with resectable metastases from colorectal cancer (CRC). We aimed to determine whether a sequential chemotherapy with dose-dense oxaliplatin (FOLFOX7) and irinotecan (FOLFIRI; irinotecan plus 5-fluorouracil/leucovorin) is superior to FOLFOX4. The chemotherapy timing was not imposed, and was perioperative or postoperative. PATIENTS AND METHODS: In this open-label, phase III trial, patients with resectable or resected metastases were randomly assigned either to 12 cycles of FOLFOX4 (oxaliplatin 85 mg/m(2)) or 6 cycles of FOLFOX7 (oxaliplatin 130 mg/m(2)) followed by 6 cycles of FOLFIRI (irinotecan 180 mg/m(2)). Randomization was done centrally, with stratification by chemotherapy timing, type of local treatment (surgery versus radiofrequency ablation with/without surgery), and Fong's prognostic score. The primary end point was 2-year disease-free survival (DFS). RESULTS: A total of 284 patients were randomized, 142 in each treatment group. Chemotherapy was perioperative in 168 (59.2%) patients and postoperative in 116 (40.8%) patients. Perioperative chemotherapy was preferentially proposed for synchronous metastases, whereas postoperative chemotherapy was more frequently used for metachronous metastases. Two-year DFS was 48.5% in the FOLFOX4 group and 50.0% in the FOLFOX7-FOLFIRI group. In the multivariable analysis, more than one metastasis [hazard ratio (HR) = 2.15] and synchronous metastases (HR = 1.63) were independent prognostic factors for shorter DFS. Five-year overall survival (OS) rate was 69.5% with FOLFOX4 versus 66.6% with FOLFOX7-FOLFIRI. CONCLUSIONS: FOLFOX7-FOLFIRI is not superior to FOLFOX4 in patients with resectable metastatic CRC. Five-year OS rates observed in both groups are the highest ever reported in this setting, possibly reflecting the pragmatic approach to chemotherapy timing. CLINICAL TRIALS NUMBER: NCT00268398.

[Recreational and competitive alpine skiing. Typical injury patterns and possibilities for prevention]. / Alpiner Skibreiten- und Skileistungssport. Typische Verletzungsmuster und Möglichkeiten der Prävention.

Alpine skiing is the most popular winter sport discipline in Germany and is performed by more than 4 million recreational sportsmen and ski racing athletes. Compared to other sports, however, the injury rate in alpine skiing is quite high. Especially the knee joint is the most commonly injured area of the musculoskeletal system. Knee injuries are classified as severe in a high percentage of cases. In this review article, epidemiologic data and typical injury patterns in recreational alpine skiing and in competitive alpine ski racing are compared. In addition, the potentials of preventive methods in alpine skiing are presented and evaluated with a special focus on orthotic devices and protection wear as injury prevention equipment.

[May eccentric training be effective in the conservative treatment of chronic supraspinatus tendinopathies? A review of the current literature]. / Kann exzentrisches Training in der konservativen Therapie von chronischen Supraspinatus-Tendinopathien effektiv sein? Eine Übersicht zur aktuellen Literatur.

Eccentric training (ET) has been shown to be an effective conservative treatment option for chronic patellar and Achilles tendinopathies. As part of the four-muscle-tendon-complex of the rotator cuff, the supraspinatus is involved most commonly in shoulder disorders. Histopathologic alterations of the supraspinatus tendon are comparable to findings in lower extremity tendinopathies. Hence, the question arises whether the concept of eccentric training can be successfully transferred to the upper extremity. Yet, no randomised controlled trials have been published to support this theory. This problem emerges from the fact that the supraspinatus is part of a complex functional unit. Consequently, surrounding soft tissues are frequently concomitantly affected. The inherent etiology and genesis of pathologic alterations in the supraspinatus tendon and its influence on shoulder disorders is not clear to date. However, the apparent success of ET in managing tendinopathies of the lower extremity urges further scientific work for developing evidence-based guidelines for the conservative treatment of tendinopathies in the shoulder region. Taking into account this lack of data as well as the anatomical and functional constraints, the aim of this work is to review the current state of the literature.

[Allografts for cruciate ligament reconstruction]. / Allogene Kreuzbandtransplantation.

Allografts have an essential significance in the surgical reconstruction of ligamentous injuries around the knee joint. While in primary anterior cruciate ligament reconstruction allografts are less important than autografts, at least in the European countries, the usage of allografts in anterior cruciate ligament revision surgery is increasing. In addition, allografts represent a good alternative for the reconstruction of the posterior cruciate ligament and the posterolateral structures. Especially in multiligament reconstructions of the knee joint, the usage of allografts may prevent iatrogenic damage of the already traumatized periarticular soft tissue. The present article focuses on the application and clinical results of allografts for ligament reconstruction around the knee joint. Furthermore, the immunological and biological principles of tendon allografts, their availability, processing, and security are discussed.

[Fractures of the lower leg in professional skiers]. / Die Unterschenkelfraktur im professionellen Skisport.

Fractures of the lower leg due to skiing accidents remain an important concern. Few studies have focussed on the special demands of professional athletes who sustain these injuries. We present our experience with three cases of lower leg fractures in competitive professional downhill skiers and discuss management and treatment concepts. We performed limited reamed compression nailing in all the patients presented because it offers the advantages of high mechanical stability and optimized fragment apposition. Plate osteosynthesis of the fibula is not required in most typical fractures. All patients resumed ski training. Two of them returned to World Cup. Only one achieved her pre-injury World Cup level of performance and success. In conclusion, a successful return for professional skiers with lower leg fractures is feasible using an optimized treatment strategy.

[Refixation of complete tendon ruptures of proximal ischio-crural muscles]. / Refixation kompletter Sehnenrupturen der proximalen ischiokruralen Muskulatur.

Complete ruptures of the proximal hamstring muscles at the ischial tuberosity are rare injuries in sports. The trigger is usually an indirect trauma with overstretching of the ischiocrural muscles. In 8 patients, the ruptured tendons were anatomically refixed using a suture anchor system. 6 patients were treated within 3 weeks after trauma, while 2 patients were operated after delayed diagnosis of more than 2 months. The follow-up was on average 25.8 (5-52) months. After rehabilitation, five patients returned to their preinjury sports level within 9-15 months on average. Indeed, 2 patients (1 primary and 1 delayed operative management) also participated in sports activities in this period of time, but could not reach their preinjury sports level completely. 1 elite athlete was still in the rehabilitation program at 5 months of individual follow-up. A postoperative complication was 1 revision because of a suture anchor dislocation after improper use of the orthosis. In four patients, incisional pain and discomfort lasting up to 2 years were noticed. In case of early diagnosis, operative treatment especially in athletically ambitious patients is the gold standard for complete ruptures of the proximal hamstring tendons. The use of a suture anchor system represents an elegant and effective technique for the treatment of ruptures of the proximal hamstring tendon complex.

[Mega-OATS. Technique and outcome]. / Mega-OATS. Technik und Ergebnisse.

Big osteochondral defects in the weight-bearing zone of the medial respectively the lateral femoral condyle are still an unsolved problem especially in younger patients. The transfer of the posterior aspect of the femoral condyle was described as a salvage procedure. Mega-OATS is a technical improvement of the transfer of the posterior condyle-procedure. Essential advantages of the conventional OATS-technique are integrated in the Mega-OATS procedure, so that iatrogenic lesions of the transferred cartilage by press-fit-fixation and secondary hardware removal can be avoided. However, the Mega-OATS procedure itself remains a salvage procedure and should only be reserved for younger patients. The results of the first series of 17 patients (average follow-up 12 (5-19) months) showed an improvement of quality of life and a significant (p = 0.003) increase in the Lysholm-score.

Barriers to social support for persons living with HIV/AIDS.

The purpose of this study was to test a barrier theory of perceived social support to HIV-positive gay men. The proposed model was tested for friends and family separately in order to investigate the uniqueness each provided. In both models, it was hypothesized that the presence of barriers to social support (availability, intimacy and disclosure) diminished acquisition of social support. The influence of barriers on the relationship between social support and health outcome (i.e. depression, t-cell count) for both friend and family models was also investigated. In general, data from HIV-positive gay men support barrier theory premises for both family and friends. Implications for helping professionals and researchers are proposed.