Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players.

BACKGROUND: There is conflicting evidence regarding extracorporeal shock wave treatment for chronic tennis elbow. HYPOTHESIS: Treatment with repetitive low-energy extracorporeal shock wave treatment is superior to repetitive placebo extra-corporeal shock wave treatment. METHODS: Seventy-eight patients enrolled in a placebo-controlled trial. All patients were tennis players with recalcitrant MRI-confirmed tennis elbow of at least 12 months' duration. Patients were randomly assigned to receive either active low-energy extracorporeal shock wave treatment given weekly for 3 weeks (treatment group 1) or an identical placebo extracorporeal shock wave treatment (sham group 2). Main outcome measure was pain during resisted wrist extension at 3 months; secondary measures were >50% reduction of pain and the Upper Extremity Function Scale. RESULTS: At 3 months, there was a significantly higher improvement in pain during resisted wrist extension in group 1 than in group 2 (mean [SD] improvement, 3.5 [2.0] and 2.0 [1.9]; P =.001 for between-group difference of improvement) and in the Upper Extremity Function Scale (mean [SD] improvement, 23.4 [14.8] and 10.9 [14.9]; P <.001 for between-group difference of improvement). In the treatment group, 65% of patients achieved at least a 50% reduction of pain, compared with 28% of patients in the sham group (P =.001 for between-group difference). CONCLUSION: Low-energy extracorporeal shock wave treatment as applied is superior to sham treatment for tennis elbow.

Complications after total knee arthroplasty: a comprehensive report.

In most reports of complications following TKA, the method of assessment and report of complications is not defined specifically. It is thus unclear whether certain complications did not occur or were simply not assessed at all. A detailed list of possible complications following TKA was developed, and the occurence of complications in 567 primary TKAs was followed up meticulously according to this list for one year postoperatively. The proportion of knees with complications was 23.6%. A revision operation was performed in 5.6%. The most frequent complication was delayed wound healing. Only a worldwide accepted standard list of well-defined complications will allow comparison of future studies on complications in TKA. For purposes of quality control, the amount of detail recorded must be weighed carefully against its practical value.

The internal calcar septum and its contact with the virtual stem in THR: a computer tomographic evaluation.

The internal calcar septum is a ridge of cortical bone protruding from the inner cortical wall of the proximal femur into the medullary canal. It extends from the lesser trochanter into the femoral neck and narrows the femoral cavity in its dorsal third. This region is essential for THR stability, but the degree of contact between the septum and standard THR implants has never been studied. We obtained CT scans of 50 arthrotic hip joints from patients requiring THR. Virtual stems (50 straight/wedge-shaped and 50 anatomic stems) were placed in CT images of the femora using a PC-based preoperative planning unit. The dimensions of the septum, degree and location of contact between the septum and implants were recorded. A septum of cortical density was seen in 49/50 CT scans. It was 11 (2.9) mm long (medial-lateral), 3.5 (0.7) mm wide and 32 (10) mm high (caudal-cranial, mean (SD)). 94/100 implanted virtual stems showed direct contact with the septum. 31 straight stems and 5 anatomical stems were supported by the septum along their dorsal side. The internal calcar septum can be consistently seen on CT scans of patients needing THR and it probably contributes to THR stability.

Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial.

OBJECTIVE: To determine the effectiveness of extracorporeal shock wave therapy compared with placebo in the treatment of chronic plantar fasciitis. DESIGN: Randomised, blinded, multicentre trial with parallel group design. SETTING: Nine hospitals and one outpatient clinic in Germany. PARTICIPANTS: 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo. MAIN OUTCOME MEASURES: Primary end point was the success rate 12 weeks after intervention based on the Roles and Maudsley score. Secondary end points encompassed subjective pain ratings and walking ability up to a year after the last intervention. RESULTS: The primary end point could be assessed in 94% (n=256) of patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group (95% confidence interval - 8.0% to 15.1%). No difference was found in the secondary end points. Few side effects were reported. CONCLUSIONS: Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis.

Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hip.

INTRODUCTION: Total joint replacement in patients suffering from developmental dysplasia of the hip poses specific technical difficulties due to insufficient bone stock at the site of the original and secondary acetabulum and a narrow, cranially displaced proximal femur. MATERIALS AND METHODS: Twelve hips with severe congenital dislocation (4 Crowe type II, 5 type III, 3 type IV) were treated with cementless, porous structured total hip replacement. The cup was implanted at the anatomic height, a femoral segment was resected below the minor trochanter to reduce the femoral component in all cases. RESULTS: One femoral component was exchanged for a longer stem after 2 months due to insufficient fit and fill. After a mean follow-up of 5.1 years, there were no further revisions or radiographic signs of loosening. No cup was revised or loose radiographically. Harris hip score (mean) improved from 36 to 82 points, mean leg length discrepancy was reduced from 5.4 to 1.3 cm. CONCLUSION: The cementless technique described is useful in cases of severe congenital dislocation of the hip when the cup is implanted at the anatomic level, and implant reduction is not possible despite thorough soft-tissue release or not advisable because of excessive limb lengthening. A reconstruction of the original joint center and good mid-term results are demonstrated.

Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial.

BACKGROUND: Recent articles have reported success with repeated low-energy shock wave application for treatment of chronic plantar fasciitis in runners. HYPOTHESIS: Shock wave treatment for chronic plantar fasciitis is safe and effective. STUDY DESIGN: Prospective, randomized, placebo-controlled trial. METHODS: Forty-five running athletes with intractable plantar heel pain for more than 12 months were enrolled; half were assigned to a treatment group that received three applications of 2100 impulses of low-energy shock waves, and half received sham treatment. Follow-up examinations were performed at 6 months and at 1 year by a blinded observer. RESULTS: After 6 months, self-assessment of pain on first walking in the morning was significantly reduced from an average of 6.9 to 2.1 points on a visual analog scale in the treatment group and from an average of 7.0 to 4.7 points in the sham group. The mean difference between groups was 2.6 points. After 12 months, there was a further reduction of pain in both groups, to an average 1.5 points in the treatment group, and to 4.4 points in the sham group. CONCLUSION: Three treatments with 2100 impulses of low-energy shock waves were a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.

Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis.

BACKGROUND: Although the application of low-energy extracorporeal shock waves to treat musculoskeletal disorders is controversial, there has been some limited, short-term evidence of its effectiveness for the treatment of chronic plantar fasciitis. METHODS: From 1993 to 1995, a prospective, two-tailed, randomized, controlled, observer-blinded pilot trial was performed to assess whether three applications of 1000 impulses of low-energy shock waves (Group I) led to a superior clinical outcome when compared with three applications of ten impulses of low-energy shock waves (Group II) in patients with intractable plantar heel pain. The sample size was 112. The main outcome measure was patient satisfaction according to a four-step score (excellent, good, acceptable, and poor) at six months. Secondary outcome measures were patient satisfaction according to the four-step score at five years and the severity of pain on manual pressure, at night, and at rest as well as the ability to walk without pain at six months and five years. RESULTS: At six months, the rate of good and excellent outcomes according to the four-step score was significantly (47%) better (p < 0.0001) in Group I than in Group II. As assessed on a visual analog scale, the score for pain caused by manual pressure at six months had decreased to 19 points, from 77 points before treatment, in Group I, whereas in Group II the ratings before treatment and at six months were 79 and 77 points (p < 0.0001 for the difference between groups). In Group I, twenty-five of forty-nine patients were able to walk completely without pain at six months compared with zero of forty-eight patients in Group II (p < 0.0001). By five years, the difference in the rates of good and excellent outcomes according to the four-step score was only 11% in favor of Group I (p = 0.071) because of a high rate of good and excellent results from subsequent surgery in Group II; the score for pain caused by manual pressure had decreased to 9 points in Group I and to 29 points in Group II (p = 0.0006 for the difference between groups). At five years, five (13%) of thirty-eight patients in Group I had undergone an operation of the heel compared with twenty-three (58%) of forty patients in Group II (p < 0.0001). CONCLUSIONS: Three treatments with 1000 impulses of low-energy shock waves appear to be an effective therapy for plantar fasciitis and may help the patient to avoid surgery for recalcitrant heel pain. In contrast, three applications of ten impulses did not improve symptoms substantially.