Short-term outcome of painful bone marrow oedema of the knee following oral treatment with iloprost or tramadol: results of an exploratory phase II study of 41 patients.

OBJECTIVES: To compare the therapeutic effects of oral iloprost and tramadol on the outcome of bone marrow oedema (BME) of the knee by MR imaging and clinical assessment. METHODS: Forty-one patients with painful ischemic or mechanical BME of the knee were enrolled in a double-blind, randomized controlled study. Patients were randomized either to iloprost (n = 21, group 1) or tramadol (n = 20, group 2). The treatment duration was 4 weeks. The Larson knee score was used to assess function before treatment and then 3 days, 1, 2, 3, 4 weeks and 3 months after the start of treatment. Short tau inversion recovery and T1-weighted MR images of the affected knees were obtained before and 3 months after the start of treatment. Bone marrow oedema was assessed visually and by computer-assisted quantification for baseline and follow-up MR examinations. RESULTS: Thirty-three patients completed the study as scheduled. The mean Larson score improved from 58.6 points to 81.8 points in group 1, and from 59.6 points to 86.8 points in group 2, after 3 months (no significant difference between the treatment groups). On MR images, complete BME regression in at least one bone was observed in nine patients (52.9%) in group 1, as opposed to three patients (18.7%) in group 2, after 3 months (P = 0.034). Correspondingly, the median BME volume decreased by 58.0% in group 1, and by 47.5% in group 2. CONCLUSIONS: The analgesic effect of iloprost and tramadol was similar. BME regression on MR images was more pronounced under iloprost treatment.

Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations.

INTRODUCTION: The main purpose of our study was to evaluate intra-articular lesions in glenohumeral-instability with arthroscopy and correlate them with clinical findings as well as history of instability. MATERIAL AND METHODS: In this prospective multi-centre study, we evaluated arthroscopic findings in 303 patients with posttraumatic anterior-inferior instability of the shoulder. The study cohort was divided into 2 groups: patients with a history of one dislocation (Group 1, n=61, 20.1%) and patients with a history of more than one dislocation (Group 2, n=242, 79.9%). RESULTS: In Group 1, 37 patients had an IGHL-lesion, 31 a MGHL-lesion and 41 a Hill-Sachs lesion. In Group 2, 182 patients had an IGHL-lesion, 172 a MGHL-lesion and 203 a Hill-Sachs lesion. The percentage of lesions in Group 2 (IGHL-75.2%, MGHL-71.1%, Hill-Sachs-83.9%) was significantly higher than in Group 1 (IGHL-60.7%, MGHL-50.8%, Hill-Sachs-67.2%, P=0.0233, P=0.0026, and P=0.0033, respectively). Within Group 2 we found significantly more Hill-Sachs-lesions with a history of an increasing number of recurrences (P=0.0436). We also found an increase of IGHL- and MGHL-lesions with an increasing number of recurrences, but this difference was not significant. The distribution of lesion types of the anterior labrum-ligament complex showed no significant difference between the two groups, apart from a higher incidence of ALPSA-lesions within Group 2 (34.7% versus 18.0% in Group 1). The results of this study show that recurrences after primary posttraumatic anterior-inferior shoulder dislocation cause increasing ligamental damage as well as increasing Hill-Sachs lesions within the gleno-humeral joint. CONCLUSION: Thus we conclude that early surgical stabilization after posttraumatic anterior-inferior shoulder dislocation is necessary to prevent increasing damage within the shoulder joint.

Ultrasound-guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder.

We carried out a prospective, randomised controlled trial on two groups of 40 patients with painful calcific tendonitis and a mean age of 48.4 years (32.5 to 67.3). All were to undergo arthroscopic removal of the calcific deposit within six months after randomisation. The 40 patients in group I received ultrasound-guided needling followed by high-energy shock-wave therapy and the 40 in group II had shock-wave therapy alone. In both groups one treatment consisting of 2500 impulses of shock waves with an energy flux density of 0.36 mJ/mm(2) was applied. The clinical and radiological outcome was assessed using the 100-point Constant shoulder scoring system and standardised radiographs. The mean follow-up was 4.1 months and no patient was lost to follow-up. Both groups had significant improvement in their Constant shoulder score. Radiographs showed disappearance of the calcific deposit in 60.0% of the shoulders in group I and in 32.5% of group II (p < 0.05). Significantly better clinical and radiological results were obtained in group I than in group II. Arthroscopic removal of the deposit was avoided in 32 patients of group I and in 22 of group II. No severe side-effects were recorded.Ultrasound-guided needling in combination with high-energy shock-wave therapy is more effective than shock-wave therapy alone in patients with symptomatic calcific tendonitis, giving significantly higher rates of elimination of the calcium deposits, better clinical results and reduction in the need for surgery.

Iloprost for the treatment of bone marrow edema in the hindfoot.

The parenteral application of the vasoactive drug, iloprost, might be a viable option for the treatment of BMES of different origins, especially ischemic ones. In edema that is secondary to osteoarthrosis or stress, the effect of therapy with iloprost depends on the grade of the basic disease. The natural course of the disease, as well as the normalization of the signal pattern of the MRI, seem to be accelerated.

Juvenile bone-marrow oedema of the acetabulum treated by iloprost.

The bone-marrow oedema syndrome is associated with local vascular disturbances and may be treated either conservatively or by core decompression after which recovery may take several weeks. We describe a 15-year-old girl with bone-marrow oedema of the left acetabulum which was confirmed by MRI. She presented with a four-week history of severe constant pain. Routine blood tests and plain radiographs were normal. She was treated with intravenous infusions of iloprost on five consecutive days (20 microg administered in 500 ml of sodium chloride). Iloprost causes vasodilatation with reduction of capillary permeability and it inhibits platelet aggregation. She had relief from pain at rest after three days of treatment and was completely free from symptoms after two weeks. MRI after six weeks showed almost complete resolution of the marrow oedema and was normal after four months. This is the first report of the pharmacological treatment of the bone-marrow oedema syndrome in children.

Treatment of bone-marrow oedema of the talus with the prostacyclin analogue iloprost. An MRI-controlled investigation of a new method.

Bone marrow oedema syndrome of the talus is a rare cause of pain in the foot, with limited options for treatment. We reviewed six patients who had been treated with five infusions of 50 microg of iloprost given over six hours on five consecutive days. Full weight-bearing was allowed as tolerated. The foot score as described by Mazur et al was used to assess function before and at one, three and six months after treatment. The mean score improved from 58 to 93 points. Plain radiographs were graded according to the Mont score and showed grade-I lesions before and after treatment, indicating that no subchondral fracture or collapse had occurred. MRI showed complete resolution of the oedema within three months. We conclude that the parenteral administration of iloprost may be used in the treatment of this syndrome.

Results of open repair of the rotator cuff--a long-term review of 79 shoulders.

In 72 patients with 79 tears of the rotator cuff that had been completely repaired by open surgery, the outcome was evaluated on the basis of history, Constant functional score and radiography. At a mean follow-up period of 6.75 years, the Constant score was 71.5 points on average, showing a high correlation with the patients' subjective satisfaction, but the score was not a reliable indicator of recurrence. The larger the cuff tear, the poorer the result was. However, deterioration was not related to the duration of follow-up or the patient's age. The presence of acromioclavicular arthrosis also had no influence on the overall result. A comparison of follow-up radiographs with those obtained immediately after surgery revealed (despite postoperative flat subacromial resection) evidence of heterotopic bone formations or ossifications in nearly half of the patients. However, except for individual cases, this had no significant influence on the clinical result or the Constant score.

Revision surgery after failed unicompartmental knee arthroplasty: a study of 35 cases.

This retrospective study evaluates the results of 35 revision procedures after failed unicompartmental knee arthroplasty (UKA) in 34 patients, which were done during the period 1986 to 1996. There were 28 women and 6 men with a mean age of 71 years (range, 54-85 years). In all cases, St. Georg and Endo (W. Link, Hamburg, Germany) unicompartmental prostheses were used except 1 PCA unicondylar implant (How medica, Rutherford, NJ) and 1 Böhler unicondylar implant (Allo Pro, Baar, Switzerland). Failures most frequently were due to aseptic loosening followed by polyethylene wear. Two deep infections occurred. Revisions were performed 1 week to 11 years after UKA; 23 were required within the first 5 years. In most cases, revision was to a total knee arthroplasty. Partial component exchange was done in 9 cases. All 34 patients were evaluated clinically after exchange arthroplasty. After a mean follow-up time of 4 years (range, 1-12.2 years), we found 11 excellent, 13 good, 4 fair, and 7 poor results according to the Hospital for Special Surgery score. The fair and poor results were due to aseptic loosening of the knee prosthesis in 6 knees. One of 2 patients with deep infection needed femoral amputation. With correct indication and considerable surgical experience, UKA is still a good alternative, especially in the elderly patient.

The incidence of thrombosis in high tibial osteotomies with and without the use of a tourniquet.

In a prospective randomised study, 65 high tibial osteotomies were performed in cases of varus osteoarthritis of the knee, and the incidence of thrombosis with and without the use of a tourniquet was studied. With an average incidence of thrombosis of 10.8%, no statistically significant differences between these two groups were seen.

Radiographic evaluation of the acromion in impingement syndrome: comparison with arthroscopic findings in 147 shoulders.

We analyzed standardized scapulolateral and anteroposterior view radiographs in 147 patients with impingement syndrome to detect a subacromial osteophyte or spur, which should be of value in those patients who require surgical treatment. Standard anteroposterior view radiographs with a fixed tube angulation, 0 and 30 degrees, were compared to anteroposterior view radiographs with individual tube angulation (the radiograph beam was tilted caudally, depending on the slope of the acromion). In all patients, we identified an acromion bony overhang on the anteroposterior view radiographs with individual tube angulation having an average thickness of 5 mm, which correlated well with the intraoperative findings at arthroscopic acromioplasty. In only 35% of the patients did we detect a subacromial osteophyte or spur on radiographs with a fixed tube at 0 degrees angulation and in 92%, we found a false impression of a spur on the 30-degree views because of overexposure. We conclude that, anteroposterior view radiographs with an individual caudally-tilted X-ray beam, depending on the acromion slope, can show the whole spur and/ or size of the osteophyte, on the anterior margin of the acromion.

Magnetic resonance arthrography (MRA) in the postoperative shoulder.

To evaluate changes in capsular mechanisms and the labroligamentous complex with magnetic resonance arthrography (MRA) after shoulder surgery and to establish possible criteria for the expected post-operative appearance of the shoulder. MRA of the shoulder was performed in 16 patients, before and 6 months after undergoing arthroscopic surgery for recurrent unidirectional dislocation. MR studies were performed after application of a constant amount of contrast solution (2 mmol Gd-DTPA). Axial and coronal oblique T1-weighted images were obtained with and without fat suppression techniques. Anterior (a) and posterior (p) capsular distances were measured, and the p/a ratio was established. Capsule thickness, capsular leaking, estimation of the volume of the axillary recess, appearance of the glenohumeral ligaments, and evidence of labral lesions were compared on pre- and postoperative images. Mean anterior capsular distance (a) decreased from 9.73 +/- 1.03 mm preoperatively to 5.27 +/- 2.49 mm postoperatively, whereas dorsal capsular distance (p) increased from 6.13 +/- 2.36 to 8.93 +/- 2.37. The p/a ratio increased from 0.64 +/- 0.25 to 2.36 +/- 2.54 (p = 0.007). Capsular leaking was suspected preoperatively in seven patients, but was not evident postoperatively. Capsular thickness and the estimated volume in the axillary recess did not change significantly. Contrast extension into pre-existent labral tears (nine patients) decreased or were not evident postoperatively. Changes in the appearance of the glenohumeral ligaments were found in six patients. Changes in capsular distances might be indicative of a decreased capsular laxity and could be a valuable criterion in the evaluation of the postoperative shoulder. Postoperative follow-up of labral tears is demonstrated by a decrease in contrast extension into or under a tear. Reactive capsular thickening or scar tissue formation can be reactive or preexistent. Changes in ligaments might be secondary to surgery. MRA may be helpful in the reevaluation of patients with suspected recurrent instability.

Stress fracture of the tibia after total knee arthroplasty.

We present a case of total knee arthroplasty in which the patient suffered a transverse stress fracture of the tibia 2 weeks after replacement without significant injury. Plain radiographs were obtained on event presentation. Later radiographic examination showed the fracture and a periosteal reaction. The fracture healed after immobilising the limb in a cast for 2 months. This case illustrates well an insufficiency fracture to the occurrence of stress risers in a weakened bone when subjected to repetitive loading as a complication following total knee arthroplasty.

Arthrodesis for traumatic flat foot. Tarsometatarsal and medial longitudinal arch fusion by inlay grafting, 11 feet followed for 1.5 years.

We examined 11 feet, 18 (11-30) months after simultaneous tarsometatarsal and medial longitudinal arch fusion to stabilize a residual mobile flat foot resulting from an injury. All had solid fusion and the surgical correction of the flat foot deformity was maintained. At the follow-up, we rated 6 feet as excellent and 5 as good. Mechanically, simultaneous arthrodesis of the tarsometatarsal joint and the longitudinal arch of the foot seem better than isolated arthrodesis of the tarsometatarsal joints.

[Carpal tunnel syndrome. A comparison of endoscopic and open surgical treatment]. / Das Karpaltunnelsyndrom. Ein Vergleich der endoskopischen und offenen operativen Behandlung.

In a prospective study, we compared open and endoscopic carpal tunnel release. From 1993 to 1994, 40 patients were operated. In 20 patients (group A) we performed an endoscopic release of the retinaculum flexorum combined with a release of the ligamentum carpi palmare. In 20 patients (group B), we performed an open release of the retinaculum flexorum, of the ligamentum carpi palmare and a neurolysis of the nervus medianus. Preoperatively, we did X-ray, clinical and electroneurographic examinations. All patients in group A and B were controlled ten days, six weeks, and three months postoperatively. The control of the electroneurographic parameters was done three months postoperatively. We did not find any significant difference between the two groups as to the X-rays, the clinical parameters and the results of the improvement of the median motor latency, the NPA and the median sensory latency. In group A as well as in group B, the improvement of the sensory latency and the distal latency was significantly higher, the improvement of the distal latency was significantly higher in group B. The duration of the surgery was significant shorter as well as the return to work for the patients with an endoscopic release.

[Arthroscopy and arthroscopic surgery of the shoulder joint]. / Arthroskopie und arthroskopische Operationsverfahren des Schultergelenkes.

Shoulder arthroscopy is a valuable procedure in unclear shoulder pain and the differential diagnosis between instability and impingement. With arthroscopic subacromial decompression comparable results to open operations can be achieved whereas in stabilizing procedures of the shoulder joint, open surgery is still superior to arthroscopic operations.

[Arthroscopic treatment possibilities of the rotator cuff]. / Arthroskopische Behandlungsmöglichkeiten an der Rotatorenmanschette.

Many open operative procedures of the rotator cuff can be done arthroscopically, especially impingement lesions, partial and complete ruptures of the rotator cuff, osteoarthritis of the acromioclavicular joint and calcific tendinitis.

Arthroscopic synovectomy of synovial tuberculosis of the knee joint.

Synovial tuberculosis is a rare, but important differential diagnosis of synovial diseases. Three cases of arthroscopic synovectomy of tubercular monarthritis affecting the knee joint are reported. The Lysholm scoring scale modified by Klein and Kloos was excellent in two cases, but poor in one. In all three cases there was an excellent improvement in the range of motion compared to the preoperative period and no deterioration of the Larsen score in the follow-up period (25-56 months postoperatively). Considering these results arthroscopic synovectomy can be recommended as an alternative to the open procedure of synovectomy.

[Results of isolated lateral retinaculum release as a treatment method in patello-femoral dysfunction]. / Ergebnisse der isolierten lateralen Retinaculumspaltung als Behandlungsmethode bei patellofemoraler Dysfunktion.

The results of lateral retinaculum-release by arthroscopic, subcutaneous and open technique on 122 patients are presented. Within a follow-up period of 3.68 years in average the postoperative success rate was 56%. The results of surgery if the cartilage of the patella was unchanged--as well as with isolated medial or lateral chondromalacia--were good. If there was medial and lateral chondromalacia the isolated retinaculum-release is insufficient. The rate of postoperative complications (effusion, haemorrhage) by arthroscopic surgery technique is with 11.1% distinctly above the results by the subcutaneous technique, which amounts to a mere 3%. The 30 degrees degree-tangential x-ray technique combined with external rotation of the lower leg and simultaneous tension of the quadriceps gives much better information of the position of the patella than the 30 degrees degree x-ray without quadriceps tension.

Improved outside-in technique of arthroscopic meniscal suture.

A technique for modified outside-in suture technique for meniscal suture repair is described. This technique is particularly useful in degerative menisci in that the positioning of the suture causes the meniscus to exert steady pressure to a larger area. There are no knots in the joint space to cause irritation or sliding of the suture.