[Knee cartilage lesions and occupational load. Results of an arthroscopic study]

AIM

Numerous epidemiological studies have suggested a relationship between knee osteoarthritis and occupational load or, respectively, a kneeling or squatting position at work. Cartilage breakdown was clearly identified as the main mechanism of the osteoarthritic process. This arthroscopic study was aimed to evaluate the relationship between frequency and grade of knee cartilage damage compared with occupational load. It was hypothesised that heavy work conditions cause higher cartilage degeneration in diverse age groups. Furthermore, it was suggested that kneeling or squatting work positions (analogous to the BK 2112) produce more severe cartilage damage or other distributions thereof compared with patients in low knee-loading professions.

METHODS

A total of 1199 patients with knee pain (history of 3 months or more) underwent arthroscopic operations. Cartilage lesions were classified according to the ICRS (International Cartilage Repair Society) protocol. The grading of joint degeneration was quantified by using the WOAKS (whole organ arthroscopic knee score). Patients were divided into 5 age groups (24-39-51-64-75 years) by analysis of cluster centres.

RESULTS

In 80.6% (n = 1086) the preoperative radiography suggested signs of a knee osteoarthritis. There was a range from grade I to grade III osteoarthritis according to the Kellgren-Lawrence score. Older female patients had knee osteoarthritis significantly (p = 0.027) more frequently. The grade of osteoarthritis correlated significantly with the patients' age (p > 0.001). The mean WOAKS was 16.6 +/- 13.7 points. There was a continuous increase of WOAKS from 8.2 +/- 5.1 in 24-year-old patients to 24.2 +/- 16.3 points in 75-year-old patients (p < 0.001). In about half of the cases cartilage lesions within the patella and trochlea were evaluated. Most frequently we recorded cartilage lesions within the mean bearing zone of the medial femoral condyle (96.2%) and the medial tibia (57.7)%. Only about a third of our patients suffered from cartilage lesions within the mean bearing zone of the lateral condyle and tibia. The frequency of cartilage lesions and the severity of the lesions grade was significantly less within the non-loaded margin of the surfaces. In 45 knees (3.8%) we found intraarticular osteophytes located: medial (n = 9) and lateral (n = 3) patella margin, intracondylar notch (n = 12), medial tibia (n = 9) and lateral margin of the lateral tibia (n = 4), lateral femoral condyle at the intersection to the lateral trochlea margin (n = 3). The occurrence of osteophytes correlated with the patients' age and the radiological grade of the osteoarthritis. There were no differences with respect to the profession within the age groups. In the non-adjusted WOAKS, patients with hard knee-loading work had a WOAKS of 16.8 +/- 13.9 points and patients with soft work a score of 17.2 +/- 14.3 points (p = 0.583). Differences in the frequency of cartilage distributions within the judged regions of the knee with respect to professional burden were also not evaluated. The same held for the frequency of intraarticular osteophytes.

CONCLUSION

Despite there is a known relation between occupational load and knee osteoarthritis no relation to cartilage degeneration was found in our arthroscopic investigation. For better understanding of work-related knee osteoarthritis prospective studies are needed urgently.

Initial load-to-failure and failure analysis in single- and double-row repair techniques for rotator cuff repair

AIM

This experimental study aimed to compare the load-to-failure rate and stiffness of single- versus double-row suture techniques for repairing rotator cuff lesions using two different suture materials. Additionally, the mode of failure of each repair was evaluated.

METHOD

In 32 sheep shoulders, a standardized tear of the infraspinatus tendon was created. Then, n = 8 specimen were randomized to four repair methods: (1) Double-row Anchor Ethibond coupled with polyester sutures, USP No. 2; (2) Double-Row Anchor HiFi with polyblend polyethylene sutures, USP No. 2; (3) Single-Row Anchor Ethibond coupled with braided polyester sutures, USP No. 2; and (4) Single-Row Anchor HiFi with braided polyblend polyethylene sutures, USP No. 2. Arthroscopic Mason-Allen stitches were placed (single-row) and combined with medial horizontal mattress stitches (double-row). All specimens were loaded to failure at a constant displacement rate on a material testing machine.

RESULTS

Group 4 showed lowest load-to-failure result with 155.7 +/- 31.1 N compared to group 1 (293.4 +/- 16.1 N) and group 2 (397.7 +/- 7.4 N) (P < 0.001). Stiffness was highest in group 2 (162 +/- 7.3 N/mm) and lowest in group 4 (84.4 +/- 19.9 mm) (P < 0.001). In group 4, the main cause of failure was due to the suture cutting through the tendon (n = 6), a failure case observed in only n = 1 specimen in group 2 (P < 0.001).

CONCLUSIONS

A double-row technique combined with arthroscopic Mason-Allen/horizontal mattress stitches provides high initial failure strength and may minimize the risk of the polyethylene sutures cutting through the tendon in rotator cuff repair when a single load force is used.

[Evaluation of cartilage defects in the knee: validity of clinical, magnetic-resonance-imaging and radiological findings compared with arthroscopy]

BACKGROUND

The study was aimed to evaluate the validity of clinical, radiological and MRI examination for cartilage defects of the knee compared with arthroscopic finding.

METHODS

Seven-hundred seventy-two patients who were suffering from knee pain over more than 3 months were evaluated clinical (grinding-sign) and with radiography and magnetic resonance imaging (MRI) and subsequent arthroscopy.

RESULTS

The grinding sign had a sensitivity of 0.39. The association of a positive grinding test with high grade cartilage defects was significant (p<0.000). In 97.4% an intact chondral surface correlated with a normal radiological finding. Subchondral sclerosis, exophytes and a joint space narrowing was significantly associated with high grade cartilage defects (p<0.000). The accuracy of MRI was 59.5%. The MRI resulted in an overestimation in 36.6% and an underestimation in 3.9%. False-positive results were significant more often assessed in low-grade cartilage defects (p<0.000).

CONCLUSIONS

Clinical signs, x-ray imaging and MRI correlate with arthroscopic findings in cases of deep cartilage lesions. In intact or low-grade degenerated cartilage often results an overestimating of these findings.

Functional outcome and general health status in patients after arthroscopic release in adhesive capsulitis

Frozen shoulder is said to be a self-limiting entity but full recovery often takes more than 2 years. For that, most patients are unwilling to tolerate painful restriction while awaiting resolution. We prospectively investigated 30 patients (16 women, 14 men) for the outcome of arthroscopic capsular release in idiopathic frozen shoulder. Results were determined by the assessment of subjective and objective parameters to estimate both shoulder function and general health status. Symptoms persisted without improvement for a minimum of 6 months of conservative treatment. Preoperative average American shoulder and elbow surgeons score (ASES) was 35, visual analog scale (VAS) to measure pain was 7, and simple shoulder test (SST) was 4. Mean scores of the physical component of SF-36 were considerably reduced. Mean forward elevation was 85 degrees , average abduction was 70 degrees , mean internal rotation was 15 degrees , and mean external rotation was 10 degrees . Patients were followed-up at 6 weeks, 3, 6, 12 months and by a mean of 36 months. Range of motion for all planes improved (P < 0.05). Median VAS reduced to 2, average ASES increased to 91, and SST enhanced to a mean of 10 (P < 0.05). We stated improvement of the physical components in the SF-36 questionnaire in particular bodily pain and the role-physical score. There were no significant differences between the measurements in the early postoperative phase compared to the mid-term follow-up (P > 0.05). Our results demonstrate that arthroscopic release of refractory idiopathic frozen shoulder combined with a gentle manipulation provides reliable expectations for improvement in both clinical and general health status for most patients. We recommend the use of a limb-specific and a general-health-status questionnaire to conclude the benefit of the surgical intervention and contribute the optimization of a therapy concept more effectively.

Factors that influence high tibial osteotomy results in patients with medial gonarthritis: a score to predict the results

OBJECTIVE

High tibial osteotomy (HTO) for the treatment of unicompartmental knee osteoarthritis in the presence of axial malalignment is recognized as an effective treatment for young and active patients. The aim of this study was to identify HTO prognostic factors.

METHODS

A total of 94 patients who had undergone HTO with additive arthroscopy were scored using the "knee injury and osteoarthritis outcome score" (KOOS). A KOOS of less than 114 points was judged as a poor outcome.

RESULTS

A total of 84 patients were available for follow-up after a time-interval of 45.9+/-7.6 (range 34-60) months. The KOOS increased from 46.1+/-11.1 to 120.3+/-40.8. The preoperative varus angle in all patients was 7.5 degrees +/-1.9 (range 5-14 degrees ). In follow-up the patients had a mean valgus angle of 3.7 degrees +/-2.5. Twenty-three patients (27.4%) had suffered a loss of correction (0.8 degrees , range 0-2 degrees ). A loss of correction correlated with a minor result in tendency. A total of 25 patients (29.8%) had a poor KOOS. Factors associated with a poor HTO outcome were a patient history of more than 24 months, a preoperative KOOS>50 points, obesity, and smoking. However, the results were also influenced by radiological findings, such as medial tibial exophyte, a medial joint space width of less than 5mm, and intraarticular damage, such as a degree IV cartilage defect of the tibia. Gender was also a minor prognostic factor. Patient's age and the event of prior surgery did not influence the outcome.

CONCLUSION

This study identified relevant factors that significantly influenced HTO results. It was possible to create a "predictive score" for HTO patients. Patients with more than 4 of the poor prognostic factors should chose primary arthroplasty.

Arthroscopic debridement of irreparable massive rotator cuff tears--a comparison of debridement alone and combined procedure with biceps tenotomy

The goal of the study was to compare the results of arthroscopic debridement in massive, irreparable rotator cuff tears with and without tenotomy of the long head of the biceps (LHB). We evaluated 41 patients who were treated by a single surgeon for massive, irreparable rotator cuff tears either by arthroscopic debridement alone (24 patients) or with additional tenotomy of LHB (17 patients). The mean age was 67 years (range: 61 to 82 years) and the average follow-up was 31 months (range: 24 to 48 months). There was no significant difference between the two groups in age, gender, pain, function, and follow-up. All patients had significant disabling pain weakness preoperatively. Assessments were made using the Constant score. The average Constant score for the group without LHB tenotomy improved from a mean of 39 points (range: 19 to 54 points) preoperatively to a mean of 67 points (range: 41 to 87 points) and for the group with additional LHB tenotomy from a mean of 41 points (range: 16 to 54 points) preoperatively to a mean of 69 points (range: 49 to 87 points) at the time of follow-up. The radiological study showed no significant narrowing of the subacromial space. No statistical significance (P > .05) was found between the two groups. However, patients with additional LHB tenotomy had a longer duration of postoperative pain relief, but final pain score difference was not statistically significant. There was no complication related to the procedure. Arthroscopic débridement of massive, irreparable rotator cuff tears provides reliable expectation for improvement in function, decrease in pain, and improvement in shoulder scores for most patients. Additional LHB tenotomy did not significantly influence the postoperative results at the latest follow-up. In our series we noted no significant humeral head migration or developing rotator cuff arthropathy.

[The prevalence of pain and deformities in the feet of adolescents. Results of a cross-sectional study]

AIM

The purpose of the study was to evaluate the prevalence of foot pain and foot deformities in adolescents. It was aimed to obtain information on the association between foot pain and foot deformities.

METHOD

A total of 2 368 adolescents (age 14.5 +/- 0.7 years) were evaluated. The frequency of foot pain was probed by using a self-reporting questionnaire. The foot deformities were evaluated during clinical examinations by school doctors.

RESULTS

The prevalence of foot pain was 14.0 % and the prevalence of foot deformities was 13.7 %. The prevalence of pain was significantly higher in adolescents with foot deformity (17.8 %) than in persons without deformity (13.4 %), p < 0.05. The prevalence of a flexible flat foot was 6.2 % and the prevalence of a rigid flat foot was 0.5 %. Other deformities registered were splay foot (2.3 %) and flexible splay-flat foot (2.0). The prevalence of hallux-valgus deformity was 3.5 %. A total of 3.5 % patients were suffering from a plantar hyperkeratosis. This was significantly correlated to a high pain prevalence (the hyperkeratosis was significantly associated with a high prevalence of pain). Significant factors which were significantly associated with foot pain were foot deformity (1.4 fold) and hyperkeratosis (75 fold). Foot pain was 1.4 fold higher in children with foot deformity and 75 fold higher in feet with hyperkeratosis.

CONCLUSION

The prevalence of foot pain and foot deformity in adolescent is high. Mild deformities (flexible flat foot and splay foot) are physiological variations without any association to foot pain. Pathological conditions that are associated with foot pain are the rigid flat foot, the hallux valgus and the cavus deformity. Plantar hyperkeratosis is an indicator of foot pathology.

Prävalenz funktioneller Beschwerden des Rückens und der Hüft- und Kniegelenke bei Adoleszenten

OBJECTIVE

To determine the prevalence of functional back, hip and knee pain in adolescents. Risk factors which are associated with these complaints also should be detected.

METHODS

A total of 2368 adolescents were included (1137 male, 1231 female, age 14.5 +/- 0.7 years). The persons were interviewed in a self-reported questionnaire about episodes of back, hip and knee pain, furthermore sociodemographic information, activity in sports and consumption of legal drugs (tobacco and alcoholic beverages). All adolescents were examined by school doctors to determine back, hip and knee pathologies.

RESULTS

A total of 62.4 % of the adolescents were suffering from musculo-skeletal pain (back 45.4 %, hip 6.4 % and knee 33.6 %). The prevalence of pathological findings was: back 18.0 %, hip 2.7 % and knee 28.5 %. Summarized the prevalence of functional pain was 34.5 % for back pain, 5.7 % for hip pain and 28.5 % for knee pain. There were significantly with functional pain associated factors. Male sex was significantly associated with functional back and hip pain. Knee pain was associated with sports activity. Adolescents who were visiting a high school and adolescents who were smoker had a significant higher prevalence of functional pain.

CONCLUSION

The majority of functional back, hip and knee pain in adolescents must be classified as functional complaints. There is a significant association with female sex, visiting a high school and the consumption of legal drugs.

Gesundheitsbezogene Kontrollüberzeugung und Lebensqualität bei chronisch Kranken nach stationärer Behandlung mit Integrativer Medizin – eine Beobachtungsstudie

BACKGROUND

In 1999 the Clinic for Internal Medicine and Integrative Medicine was founded in Essen as a regular part of the German inpatient health care system. Integrative medicine (standard internal medicine, evidence-based complementary and alternative medicine combined with intensified lifestyle modification) aims to help patients with chronic illness to cope with their condition more effectively and to achieve a health-promoting lifestyle. Techniques include cognitive restructuring, the elicitation of the relaxation response, and lifestyle education. The goal is to increase health-related quality of life (QoL) as well as control beliefs and to reduce morbidity in later life.

AIM

To demonstrate changes in quality of life, lifestyle, and control beliefs after a two-week hospital stay.

METHODS

Uncontrolled prospective observational study with 557 consecutive hospital patients. Outcome parameters were quality of life (SF36), control beliefs (GKU), and daily health-related behavior (nutrition, physical activity, relaxation) on admission, at discharge, as well as 3 and 6 months after discharge.

RESULTS

Weekly physical activity increases by 29%, consumption of not recommendable foods decreases by 18%. The majority of patients (57%) engage in relaxation exercises 6 months after discharge (on admission 23%). The physical sum scale (SF36) increases from 33.9 (95% KI 32.5-35.3) on admission to 37.3 (35.8-38.9) 6 months after discharge, the mental sum scale from 41.2 (39.5-42.9) to 45.1 (43.5-46.7). The ratio internal/external control belief rises from 1.17 (95% KI 1.11-1.24) to 1.32 (1.24-1.40). Pretherapeutic ratio internal/external control belief and its increase are associated with rises in QoL.

CONCLUSIONS

After integrative medicine treatment a lasting increase in QoL and lifestyle changes can be achieved. Reinforcement of internal control beliefs and own competence is possible and enhances outcomes in chronically ill patients.

[Arthroscopic joint debridement for gonarthrosis: influence of degree of chondral damage and muscle weakness on results]

AIM

Purpose of this study was to investigate the correlation between subjective patient discomfort, chondral damage and muscular weakness in cases of gonarthrosis (OA).

METHODS

In 22 patients suffering from OA who underwent arthroscopy, the complaints were scored by the Lysholm score. Chondral damage was determined by a special "chondral score". The maximum peak torque was measured pre- and postoperatively (isokinetic test, Cybex 6000 dynamometer).

RESULTS

Joint debridement and subsequent postoperative aggressive rehabilitation produced a significant increase in the Lysholm score (from 45.7 to 77.5 points). Subjective complaints correlated significantly with the degree of chondral damage. After treatment, the strength of the extensor muscles increased significantly. The strength of the flexor muscles strength also increased tendentially. However, there was a deficit in muscular strength in comparison to the contralateral leg in all cases. The subjective complaints correlated with the loss of muscle strength at slow angular velocities.

CONCLUSIONS

The patients" evaluation with the Lysholm score in combination with an arthroscopic chondral score and the measurement of the isokinetic muscle strength is a suitable method to obtain information about the chances of success for arthroscopic joint debridement in patients suffering from OA. Arthroscopic treatment is an appropriate measure for a short-term reduction of subjective complaints in OA. But it is also useful to reduce muscular deficits.

[Biomechanical properties (compressive strength and compressive pressure at break) of hyaline cartilage under axial load]

INTENTION OF THE STUDY

Explanations concerning the physical properties of hyaline cartilage are different. It was the intention of this study to determine the material parameters of hyaline cartilage under axial load (elasticity, plasticity, elasticity and module pressure stress to break).

METHODS

Specimens from the medial femoral condyle (chondro-cortical ships) from adult female domestic pigs (n=28) were used for the experiments. The specimens were completely embedded in plaster to minimize shearing. Axial load was carried out by an universal mechanical testing machine (Zwick Z2.5/TS1S, Ulm, Germany) to determine elastic and plastic deformation and pressure stress to break.

RESULTS

Axial load up to 5 MPa produces an almost elastic deformation, an increasing axial load results in a plastic deformation. In the range of 3 to 5 MPa the principle of Hooke is valid. The elasticity module amounted to 39.2 +/- 11.9 N/mm(2), determined under 3.8 MPa axial load. An axial load of 25.8 +/- 5.2 MPa (sigma max ) causes a break of cartilage. A strong correlation between break resistance and thickness of the chondral slice (r=0.71; p < 0.05) was observed.

CONCLUSIONS

The low module of chondral elasticity characterizes this tissue as "soft". Moderate axial load causes an ideal elastic, higher axial load a plastic deformation. The medium pressure to break to amounted 25.8 MPa. The medium pressure to break of 25.8 MPa is comparable with the forces produced by an unrestrained limited downfall from a height of 4.3 m. It must be concluded that isolated chondral fractures are rare consequences of a trauma as long as accompanying ligamentous or osseous damages are not found.

[Smoking cessation for hospital staff. A controlled intervention study]

BACKGROUND AND OBJECTIVE

Smoking prevalence in Germany remains high instead of public information and education. Smoke free hospitals are propagated, but frequently the smoking prevalence in hospital staff is even higher than in the general population. The objectives of the study were to determine the prevalence of smoking amongst hospital employees in a German teaching hospital and subsequently to promote and optimise smoking cessation within controlled trial with additional evaluation of mindfulness based stress reduction, supported by a common workplace action.

PATIENTS AND METHODS

A hospital survey was carried out by anonymous questionnaires. Participation in a physician-supervised smoking cessation program with nicotine replacement, brief intervention and, additionally, in a 20-hour stress reduction program over 8 weeks (group B) was offered to all smokers. Primary outcomes were abstinence rates at 3 months, secondary endpoints included abstinence rates at 6 months, cigarette consumption in smokers and expiratory CO-concentration.

RESULTS

Out of 345 employees 296 (86 %) revealed their smoking status, 140 were smokers (47,3 %). 116 of 140 smokers agreed with participation in a smoking cessation program. 53 subjects participated additionally in the stress reduction groups (Group B), 63 subjects wished no additional stress reduction (Group A). Abstinence rates at 3 and 6 months were 38,2 % and 29,7 % for all subjects. Participants with stress reduction showed non-significant higher abstinence rates (3 months: A: 35 % vs. B: 42 % and 6 months: A: 20 % vs. B: 41,2 %), a significant lower CO-concentration and a lower smoking intensity in recurrent smokers.

CONCLUSION

With a common work place action a substantial part of employees quits smoking. Thus, the study provides support for the active promotion of physician-supervised smoking cessation programs among hospital employees. Supportive mindfulness-based stress reduction may enhance smoking cessation, yet has to be further tested in larger randomised controlled trials.