Joint line is well restored when navigation surgery is performed for total knee arthroplasty.

PURPOSE: The incorrect restoration of the joint line during TKA can result in joint instability, anterior knee pain, limited range of motion, and joint stiffness. The joint line level is usually measured only on pre- and post-operative radiographs. Current knee navigation systems can now potentially support intra-operatively joint line restoration by controlling the exact amount of the bone-cartilage removed and the corresponding overall thickness of the components implanted. The aim of this study was to assess how well the joint line level is restored and the tibiofemoral overstuffing prevented when standard knee surgical navigation is used carefully also with these purposes. Intra-operative measurements during navigated TKA were taken. METHODS: Sixty-seven primary TKAs were followed prospectively. The variation before and after prosthesis component implantation of the joint line level, both in the femoral and tibial reference, was measured intra-operatively by an instrumented probe. Overstuffing was measured as the difference between the overall craniocaudal thickness of the femoral and tibial prosthesis components inserted and the thickness of the bone-cartilage removed. RESULTS: A significant elevation in the joint line level after prosthesis implantation was found with respect to the tibial reference (1.9 ± 2.4 mm, mean ± SD), very little to the femoral reference (0.3 ± 2.1 mm), perhaps accounted for the femur-first operative technique utilized. Overstuffing was on the average of 2.2 ± 3.0 mm. CONCLUSIONS: These results suggest that a knee navigation system can also support well a proper restoration of the joint line level and limit the risk of overstuffing when relevant measurements are taken carefully during operation. LEVEL OF EVIDENCE: III.

[Is there a correlation between S100 beta and post-concussion symptoms after mild traumatic brain injury?]. / Gibt es einen Zusammenhang zwischen erhöhten S100beta-Werten und postkommotionellen Symptomen nach einer leichten Gehirnerschütterung?

In the past a lot of patients suffered from post-concussive symptoms (PCS) after mild traumatic brain injury (mTBI). The present prospective study (n = 73) was intended to help predict the outcome after mTBI with blood asservation for analysis of S100 beta 3 hours after trauma. There was no statistically significant correlation be-tween PCS or even of single symptoms and elevated marker levels. Serum S100 beta appears to be a poor predictor of the outcome following mild TBI. Establishing a diagnosis of "PCS" will still be hard in future, since no objective diagnostic -method exists. The most important facts are a precise examination and a history of the patient with a negative CT scan of the head.

[The undetected brain lesion in sports. Minor traumatic brain injury and its sequelae]. / Die unerkannte Hirnverletzung im Sport. Das leichte Schädel-Hirn-Trauma und seine Folgen.

The minor traumatic brain injury (mTBI) in sports is often looked at as a bagatelle. The treating physician underestimates the severity of the injury suspecting that a mTBI is a nonstructural lesion with an overall excellent prognosis in the majority of the cases. This paper shows that the minor traumatic brain injury may be a structural brain lesion with potentially life-threatening dangers. The therapy should follow exactly defined guidelines, e.g., stepwise protocol of the Concussion in Sports (CIS-) Group. Return to sports activities should happen only when all physical but also cognitive symptoms have subsided. All mTBIs that have been sustained prior to the actual injury have to be recorded properly because repeated mTBIs may cause chronic degenerative brain damage. Neuropsychological testing will aid in the correct diagnosis of a mTBI and is a useful parameter in the course of the injury. In the future biochemical markers may serve as indicators of the severity of the brain injury and may also aid in predicting the outcome after TBI. Today biochemical markers do not serve as a substitute for neuroimaging.

The avoidability of head and neck injuries in ice hockey: an historical review.

The number of minor traumatic brain injury (mTBI), cerebral concussions, is increasing and cannot be eliminated by any kind of equipment. Prevention strategies, such as the introduction of "checking from behind" rules have become effective in decreasing the number of severe spinal injuries. A new "head checking" rule should reduce mTBI in the same way in the following years. Mouthguards should be mandatory as an effective device for the prevention of dental and orofacial injuries, as well as reducing the incidence and severity of mTBI. A new internet database system, the International Sports Injury System (ISIS) should improve epidemiological analysis of head, face, and spinal injuries worldwide. ISIS should provide an internationally compatible system for continuous monitoring of risk factors, protective effects of equipment, and protective effects of equipment and effects of changes in rules through the years.

Outcomes after partial neurectomy of Morton's neuroma related to preoperative case histories, clinical findings, and findings on magnetic resonance imaging scans.

Our purpose was to evaluate the reliability of preoperative case histories, clinical findings, and magnetic resonance imaging (MRI) scans in substantiating the diagnosis of Morton's neuroma and in predicting clinical outcomes after surgical intermetatarsal neurectomy. We studied 19 consecutive patients with histologically proved Morton's neuroma. All had preoperative MRI of the forefoot. Partial neurectomy was performed when there was forefoot pain with transmetatarsal compression and positive findings on MRI scans. Case histories, clinical findings, and findings on MRI scans were correlated with clinical outcomes. Preoperative clinical findings including localization correlated with intraoperative findings in 11 of 19 patients (58%), and MRI scans correlated in 16 of 19 patients (84%). Of the 19 patients, 74% achieved satisfactory outcomes. Neither reliable clinical findings or findings on MRI scans nor confirmation of clinical findings by MRI correlated with a superior result, but 77% of patients with neuromas measuring more than 5 mm in transverse measurement on MRI scans had good outcomes; only 17% with neuromas measuring 5 mm or less had good outcomes. Preoperative localization and diagnosis of Morton's neuroma is better achieved with MRI than through clinical findings. A more favorable clinical outcome can be expected after surgical intermetatarsal neurectomy when a Morton's neuroma has a transverse measurement larger than 5 mm on MRI scans.

Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA.

We have compared the efficacy of patient-controlled interscalene analgesia (PCIA) using ropivacaine with patient-controlled analgesia (PCA) using nicomorphine in 60 patients (n = 30 in each group), in a prospective, randomized study. In both groups, all patients received interscalene block with 0.75% ropivacaine before induction of anaesthesia. Six hours after interscalene block, patients in group PCIA received continuous infusion of 0.2% ropivacaine at a rate of 5 ml h-1 with a bolus dose of 3 or 4 ml and a lockout time of 20 min; patients in group PCA received continuous infusion of nicomorphine 0.5 mg h-1 and a bolus dose of 2 or 3 mg with a lockout time of 20 min. Control of pain was significantly better from 12 to 48 h after operation (except at 42 h) in group PCIA. Nausea and pruritus occurred significantly more frequently in group PCA. Patient satisfaction was greater in group PCIA. We conclude that the use of 0.2% ropivacaine using PCIA was an efficient way of managing pain after major shoulder surgery and compared favourably with PCA nicomorphine in terms of pain relief, side effects and patient satisfaction.

Patient-controlled analgesia after major shoulder surgery: patient-controlled interscalene analgesia versus patient-controlled analgesia.

BACKGROUND: The authors compared patient-controlled interscalene analgesia (PCIA) with local anesthetics with intravenous patient-controlled analgesia (PCA) with opioids to manage postoperative pain after major shoulder surgery. METHODS: Forty patients scheduled for elective major shoulder surgery were prospectively randomized to receive either PCIA or PCA. Before surgery, all patients had an interscalene block. In the PCIA group, a catheter was introduced within the interscalene sheath. Six hours after the initial block, patients received for 48 h either a continuous infusion of 0.15% bupivacaine through the interscalene catheter at a rate of 5 ml/h plus a bolus of 3 or 4 ml with a lock-time of 20 min (group PCLA) or a continuous intravenous infusion of nicomorphine at a rate of 0.5 mg/h plus a bolus of 2 or 3 mg with a lock-time of 20 min (group PCA). Pain relief was regularly assessed using a visual analog scale, side effects were noted, and the patients were asked to rate their satisfaction at the end of the study. RESULTS: Pain relief was significantly better controlled in the PCIA group at t = 12 and 18 h (P < 0.05). Vomiting and pruritus were 0 versus 25% and 0 versus 25% for the PCIA and PCA groups, respectively (P < 0.05). Patient satisfaction was greater in the PCIA group (P < 0.05). Time of first bolus administration and paracetamol supplement were similar in both groups. CONCLUSIONS: The use of the PCIA technique was uncomplicated and provided better pain relief than PCA during the first 18 h after operation. The incidence of side effects such as vomiting and pruritus was significantly decreased with the use of PCIA, and patient satisfaction was superior in the PCIA group.

[Assessment of shoulder pain in athletes]. / Abklärung von Schulterschmerzen beim Sportler.

The shoulder joint, the most movable joint in our body, is exposed to a considerable load during many sporting activities. The shoulder can be injured and limited in its function not only by direct and indirect trauma but also by repetitive load. Sports with body contact may cause bruises, glenohumeral and acromio-clavicular dislocations or strains of the rotator cuff. Any repetitive microtrauma, particularly those involving sporting activities requiring repetitive overhead use of the arm, may develop lesions of tendons, glenohumeral instabilities or impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim and may be frequently the cause of shoulder pain in athletes. After an introduction to the anatomy of the shoulder and an illustration of the biomechanics of throwing, we explain shoulder pains in the athlete caused by tendon lesions, joint instability and by neurovascular shoulder problems with the typical patient history, the clinical signs, physical and imaging studies in detail. Among the typical lesion of tendons we are describing the impingement syndrome of the supraspinatus tendon, the lesions of the biceps tendon and the impingement of the lower surface of the cuff on the postero-superior glenoid labrum. As glenohumeral instability we describe the anterior, posterior, and inferior instability and the multidirectional instability as well. As neurovascular shoulder problems we describe anatomy, function, patient history, etiology, clinical signs, physical examination, differential diagnosis, therapy, and prognosis of lesions of the nervi suprascapularis, axillaris, thoracicus longus, musculocutaneus, and accessorius as well as lesions of the plexus brachialis and in the thoracic outlet syndrome.

Review of typical ice hockey injuries. Survey of the North American NHL and Hockey Canada versus European leagues.

Ice hockey is considered to be one of the fastest and roughest of all sports. Prospective injury reports of the North American National Hockey League, the Canadian Amateur Hockey Association and of several European teams (UdSSR, CSSR, Sweden and Switzerland) are reviewed to evaluate the patterns, anatomic locations, circumstances and sequelae of ice hockey-related injuries. Although different injury reporting systems are used in North America and Europe, knee injuries (sprains of the collateral ligaments) accounted for the majority of games missed (40%), followed by injuries to the shoulder (dislocation, acromio-clavicular joint separation, rotator cuff strain and tears, 20%), the groin (15%), and the back (10%). Mandatory helmets and face masks reduced the number of facial and eye injuries to a quarter from 1972 to 1983. The frequency of only concussion but also cervical spine lesions is increasing. The prevention of head, face, eye and neck injuries should mainly be accomplished by enforcement of current rules (mandatory helmets with face masks) and institution of new rules. Improvement in protective equipment would also have the effect of decreasing the frequency of injuries. Ice hockey is the fastest team sport and involves both finesse and controlled aggression. It is also considered to be one of the roughest of all sports. In recent years, ice hockey has grown tremendously in popularity, not only in the United States and in Canada but also in many European countries [1]. The number of both professional and amateur hockey players has increased with the expanding interest in the sport around the world [1].(ABSTRACT TRUNCATED AT 250 WORDS)

[An overview of snow-boarding injuries]. / Ubersicht der Snowboardverletzungen.

Snowboarding is increasing dramatically in popularity in Switzerland as well as other countries. Work aimed at improving the design of the boards and of the boots and bindings has also increased rapidly during recent years. Most injured snowboarders are fit young men and boys who describe themselves as beginners and have had a minimal amount of instruction at an officially approved training centre. Appropriate snowboard training has mostly been quite inadequate, and protective devices (e.g. waterproofed support gloves). The anatomical distribution and the types of injuries sustained in snowboarding differ from those in alpine skiing. The wrist (and forearm) and the ankle are the most frequent locations of injuries (23%) as against the knee and thumb in alpine skiing. Sprains and strains were the most frequent types of injuries (46%), followed by fractures (28%) and contusions (13.5%). The snowboard injury rate was higher than in alpine skiing (1.7-8/1000 snowboard days versus 2-4/1000 ski days). Falling forward on the slope was the major mechanism of injury (80%), and torsion the next most frequent (20%). Snowboarding injuries were sustained most often on ice and hardpacked snow, compared with soft powder snow for alpine skiing injuries. Appropriate preseason conditioning, snowboarding lessons from a certified instructor, appropriate selection of rigorously tested equipment and use of protective devices are the main steps that must be taken to prevent injuries.

[Head injuries in ice hockey exemplified by the National Hockey League "Hockey Canada" and European teams]. / Kopfverletzungen im Eishockey am Beispiel der National Hockey League, "Hockey Canada" sowie europäischer Teams.

Ice hockey is one of the fastest and roughest of all sports. Based on prospective injuries reports of the North American National Hockey League, the Canadian Amateur Hockey Association and three European teams (USSR, Sweden and Switzerland) the patterns, topography, circumstances and sequelae of the head injuries related to ice hockey are described. Although mandatory helmets and face masks have reduced the large number of facial and eye injuries, the rates of head injury and concussion are still to high. A number of steps must be taken by the hockey organisations, players, equipment manufacturers and health-care professionals to prevent injuries for specific prevention of head, face and eye injuries the rules should be strictly enforced, e.g. no checks from behind, high-sticking penalties, and mandatory helmets with face masks.