Platelet-rich plasma (PRP) as therapy for cartilage, tendon and muscle damage - German working group position statement

Purpose

Platelet rich plasma (PRP) is widely used in orthopaedics, but is still heavily debated. Therefore, a survey among the German “Working Group for Clinical Tissue Regeneration” of the German Society of Orthopaedics and Traumatology was conducted to achieve a consensus about the current therapeutical potential of PRP.

Methods

A first survey (n = 65 experts, all orthopaedic/trauma surgeons) was conducted (n = 13 questions). Following, a second round (n = 40 experts) was conducted with 31 questions to achieve consensus in 5 categories: three most common indications, PRP application, future research areas.

Results

Therapeutic PRP application was regarded as useful (89%), possibly even more important in the future (90%). Most common indications were tendon pathologies (77%), osteoarthritis (OA) (68%), muscle injuries (57%) and cartilage damage (51%). Consensus was reached in 16/31 statements. The application of PRP for early knee OA (Kellgren-Lawrence grade II) was regarded as potentially useful, as well as for acute and chronic tendinopathies. For chronic lesions (cartilage, tendons), multiple injections (2–4) were seen preferable to singular injections. However, no sufficient data exists on the time interval between the injections. Standardization of PRP preparation, application, frequency, as well as determining the range of indication is strongly recommended.

Conclusions

There is a need of further standardization of the PRP preparation methods, indication and application protocols for knee OA and other indications, which must be further evaluated in basic science studies and randomized controlled clinical trials.

Level of evidence

Consensus of expert opinion, Level V.

[Back pain : State of the art and guidelines]

Pain in general and back pain in particular are associated with a variety of pathological, clinical, and sociocultural factors. There are numerous clinical and therapeutic treatment as well as imaging-options available and comprehensive knowledge is required to meet the individual clinical needs of those affected. This requires a high degree of interdisciplinary cooperation. In addition, back pain is covered differently by various numbers of insurance companies. Imaging methods, including the example of periradicular image-assisted interventions, are presented with regard to their indication and efficiency. The existing guidelines and evaluation recommendations with different structural and targeted approaches are discussed in addition to extensive legal aspects in the literature. In addition, the structured reports and the certificated curricula of the AG Bildgebende Verfahren des Bewegungsapparates (Working Group "Imaging Procedures of the Musculoskeletal System") of the Deutsche Röntgengesellschaft ("German Society of Radiology") are recommended for the quality assurance.

[Osteoarthritis classifications : Modification proposal for the criteria of Kellgren and Vallotton]

BACKGROUND

In imaging diagnostics, classification schemes are very common. As far as osteoarthritis is concerned, the Kellgren classification is the most popular. However, the Kellgren classification, which has been used for more than 50 years, is based on nonspecific criteria; thus, high interobserver variability has been reported. In addition, the Kellgren classifications have not been coordinated with magnetic resonance imaging (MRI)-based classification schemes, e.g., Vallotton.

AIM

In this paper, we present some modifications concerning the criteria for both the Kellgren classification and its comparison with the MRI-based Vallotton classification.

METHODS

The current surgical and imaging classifications and the precision of the nomenclature are analyzed. X‑ray and MRI findings are compared.

RESULTS

Suggestions for both a modification of the Kellgren classification as far as the criteria are concerned and a hierarchy (ranking) of X‑ray and MRI findings to make clinical decisions more valuable are proposed.

CONCLUSION

These proposed modifications (Kellgren and ranking) would be helpful for routine reporting and allow for better interobserver reliability, in particular for special reports (e.g. consultations, expert opinions, advanced diagnostics).

Degenerative isolated cartilage defects of the patellofemoral joint are associated with more severe symptoms compared to trauma-related defects: results of the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

The purpose of this study was to utilize data from the German Cartilage Registry (KnorpelRegister DGOU) to examine the hypothesis that degenerative cartilage defects of the patellofemoral joint are associated with more severe clinical symptoms compared to trauma-related defects.

METHODS

All patients with isolated focal cartilage defects of the patellofemoral joint registered in the German Cartilage Registry until May 2017 were included in the study. Patients with previous surgery of the ipsilateral knee were excluded. Baseline data including etiology (traumatic, degenerative), size, location and ICRS grade of the cartilage defects as well as the duration of symptoms were analyzed. Clinical symptoms were evaluated by means of the numeric analog scale (NAS) for pain and the Knee injury and Osteoarthritis Outcome Score (KOOS). Group comparisons were performed using the Mann-Whitney-U test along with the Chi-squared test and Fisher's exact test. A bivariate correlation analysis and a multivariable linear regression analysis were performed to investigate the association between the defect characteristics and the clinical scores.

RESULTS

A total of 423 patients (203 traumatic and 220 degenerative defects) were included. Isolated degenerative cartilage defects were found to have significantly more trochlear locations (28% vs. 18%; p = 0.006), significantly less ICRS grade 4 lesions (50% vs. 73%; p = 0.002) and a significantly smaller defect size [median 300 (IQR 105-400) vs. 300 (200-400) mm²] when compared to those from traumatic etiology. Traumatic defects showed significantly better KOOS-ADL [77 (60-90) vs. 69 (56-82); p = 0.005], KOOS-pain [69 (56-81) vs. 61 (47-75); p = 0.001] and NAS [2 (1-5) vs. 4 (1-6); p = 0.005] scores compared to degenerative defects. The correlation analysis revealed only weak correlations between the quantitative defect characteristics and clinical scores.

CONCLUSIONS

Degenerative isolated cartilage defects in the patellofemoral joint are associated with more severe clinical symptoms in comparison to trauma-related defects. Additionally, they show a larger variance regarding their location with more trochlear defects.

LEVEL OF EVIDENCE

III.

[Prognostic assessment in private healthcare insurance part 1 : Risk of osteoarthritis]

After examining the cause of an accident the medical expert working in the area of private health care insurance under the general accident insurance (AUB) sample conditions must ascertain incapacity within a period of time that has been contractually agreed upon between the parties involved. In addition, this person must also state their position on the question as to whether there may exist any circumstances up to the latest possible point in time in insurance terms that would comprise an adequate prognosis of a future change in the long-term condition. This requires a high probability.The sole risk of the evolution of the functional deficit arising from a proven or prognosticated post-traumatic osteoarthritis is excluded from this standard of proof which means that flat-rate risk supplements are not suited to this individualized approach and thus do not apply.

[Prognostic assessment in private healthcare insurance part 2 : Risk supplement for accidental endoprostheses]

After examining the causes of an accident the medical expert working in the area of private health care insurance under the general accident insurance (AUB) sample conditions must ascertain incapacity within a period of time that has been contractually agreed between the parties involved. In addition, this must also state their position on the question as to whether there may exist any circumstances up to the latest possible point in time in insurance terms that would comprise an adequate prognosis of a future change in the long-term condition. This requires a high probability. In contrast to scientifically based findings serving as a prognosis of osteoarthritis, in the case of endoprostheses forecasts can only be based on medical experience, which in this case has to satisfy the standard of proof of a high level of probability, since necessary replacement operations after insertion of a prosthesis are sufficiently probable. The prosthesis supplements that have been applied to date in the context of an assessment of prognosis have their justification. In applying them, however, it must be considered on one hand that this supplement is comprised of an equally weighted proportion for future risk and on the other hand a preventive portion. This increases in significance with different prostheses on one and the same limb.

[Treatment of Osteochondral Lesions in the Ankle: A Guideline from the Group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU)]

Background: Osteochondral lesions (OCL) of the ankle are a common cause of ankle pain. Although the precise pathophysiology has not been fully elucidated, it can be assumed that a variety of factors are responsible, mainly including traumatic events such as ankle sprains. Advances in arthroscopy and imaging techniques, in particular magnetic resonance imaging (MRI), have improved the possibilities for the diagnosis of OCLs of the ankle. Moreover, these technologies aim at developing new classification systems and modern treatment strategies. Material and Methods: This article is a review of the literature. Recommendations of the group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU) for the treatment of OCLs of the ankle are presented. The review gives a concise overview on the results of clinical studies and discusses advantages and disadvantages of different treatment strategies. Results: Non-operative treatment shows good results for selected indications in children and adolescents, especially in early stages of osteochondritis dissecans (OCD). However, surgical treatment is usually indicated in OCLs in adolescents and adults, depending on the size and location of the lesion. Various arthroscopic and open procedures are frequently employed, including reattachment of the fragment, local debridement of the lesion with fragment removal and curettage of the lesion, bone marrow-stimulation by microfracture or microdrilling (antegrade or retrograde), and autologous matrix-induced chondrogenesis (AMIC®) - with or without reconstruction of a subchondral bone defect or cyst by autologous cancellous bone grafting. Isolated subchondral cysts with an intact cartilage surface can be treated by retrograde drilling and possibly additional retrograde bone grafting. For larger defects or as salvage procedure, osteochondral cylinder transplantation (OATS® or Mosaicplasty®) or matrix-induced autologous chondrocyte transplantation (MACT) are recommended. Transplantation of so-called (osteochondral) mega grafts, such as autologous bone grafts or allografts, are used for very large osteochondral defects that cannot be reconstructed otherwise. Implantation of the so-called "small metal implants" - such as HemiCAP Talus® - is reserved for selected cases after failed primary reconstruction. Corrective osteotomies are indicated in accompanying axial malalignments. Conclusions: There are several different treatment strategies for OCLs, but clinical studies are rare and evidence is limited. Therefore, interventional studies, e.g. randomised controlled trials (RCTs), but also observational studies, e.g. based on data of the Cartilage Registry of the German Society of Orthopaedics and Traumatology (www.knorpelregister-dgou.de), are needed and are recommended by the authors.

[The time-related risk for knee osteoarthritis after ACL injury. Results from a systematic review]

AIM

The aim of this review was to evaluate the time-related risk for knee osteoarthritis in patients after ACL injury.

MATERIALS AND METHODS

The primary search was carried out in different medical databases with the deadline 12.01.2014. The search strategy for the evaluation was [ACL] AND [osteoarthritis] including "all fields". All 1656 title/abstracts were reviewed by two independent researchers who selected 140 papers for full text review. Finally, a total of 21 relevant publications were identified for inclusion in this current paper.

RESULTS

The incidence of knee osteoarthritis rises significantly over time. Two years after injury it was 6.9%, after 5 years 32.2%, after 7 years 36.3%, and after 10 years 79.6%. At the same time, the crude relative risk of OA rises as the time interval since injury increases. The relative risk of OA has already doubled by 2 years after ACL injury). By 7 years it has increased fivefold and compared with OA status at the time of injury it is still increasing significantly after 10 years.

CONCLUSIONS

The ACL injury is a significant risk factor for the development of early-onset secondary knee osteoarthritis. Within 5 years of the injury the knee shows clear signs of osteoarthritis on MRI. However, these lesions are often not associated with any clinical signs. Knee osteoarthritis as a severe disease starts 8 years or later after the injury, when it requires treatment.

[Bone Marrow Lesion - Risk-Factors and Pathophysiological Relevance: Systematic Review]

AIM

The objective of this systematic review and meta-analysis is to obtain information about risks and associated factors for knee symptoms and the progression of osteoarthritis in idiopathic bone marrow lesion (BML).

MATERIALS AND METHODS

The primary search on 31. 12. 2013 included the databases PubMed, EMBASE, Web of Science and Cochrane by the search strategy [[bone marrow edema] AND [knee]]. This review was continuously updated up to 31. 10. 2015.

RESULTS

A total of 30 studies (from 1331 primary findings) were included in the final evaluation. The mean frequency of BML in all studies was 37.2 %. The occurrence of BML was strongly dependent on the MRI technique used (1.0 to 3.0 T). In longitudinal studies, the incidence of BML was 3.2 (95 % CI 1.7-6.3)/1000 person-months. Weakly associated factors included female gender (OR = 1.3 [95 % CI 1.1-1.7], p = 0.009), increasing age (OR = 1.05 [95 % CI 0.9-1.3], p = 0.127), and overweight or obesity (OR = 1.1 [95 % CI 1.1-1.2]; p < 0.01). BMLs are significantly associated with cartilage lesions (OR = 5.5 [95 % CI 1.3-22.5]). Radiological osteoarthritis is also significantly associated with the development of BML (OR = 3.6 [95 % CI 1.2-10.6]) and the progression of osteoarthritis within a 3-year interval (OR = 4.4 [95 % CI 3.1-6.4]).

CONCLUSIONS

The occurrence of BML is an important index for severe degenerative pathologies in the knee. It appears that MRT symptoms predict the progression of the disease. The clinical relevance and possible consequences for treatment are unclear.

[Characteristics of Focal Degenerative Cartilage Lesions in the Knee Joint. A Radiologic, Spectroscopic, Histological and Biochemical Study]

OBJECTIVE

The aim of this study was to perform a macroscopic, spectroscopic and biochemical/histological examination of the defect margins of grade IIIb cartilage lesions in the patella, the medial femoral condyle, the corresponding articular surface and the remaining cartilage surfaces of the knee joint. Our null hypothesis was that there would be no difference in characteristics between the cartilage surrounding the defect, the corresponding articular surface and the remaining articular surfaces of the knee joint on the one hand and the cartilage within the defect on the other.

METHOD

The study included ten patients treated for focal cartilage lesions (ICRS classification grade IIIb) by autologous cartilage transplantation (ACT). All patients underwent a preoperative magnetic resonance imaging scan (1, 5 T). The articular cartilage lesions were classified pursuant to the recommendations of the International Cartilage Repair Society (ICRS). During the arthroscopic procedure, spectroscopic examinations were performed to measure the degree of cartilage degeneration in a total of 14 defined areas including the defect itself and the region of the defect margins. Biopsies for a histological and biochemical examination (collagen II, glycosaminoglycan, DNA) were taken from the centre of the defect and the defect margins that seemed to be intact on macroscopic examination.

RESULTS

All knee joints had focal grade IIIb cartilage lesions with an intact margin and an intact corresponding articular surface. The readings obtained on spectroscopic examination both in the defect, the apparently intact margins, the corresponding articular surface and all other examined areas of the knee suggested that severe degenerative changes had already occurred in the cartilage. The histological and biochemical examinations of the residual cartilage in the centre of the defect and the apparently intact margins revealed no significant differences.

CONCLUSIONS

Focal cartilage lesions frequently occur in the main weight-bearing zones of the patella and the medial femoral condyle. If they are the result of degenerative changes in the knee joint, the residual cartilage in the defect does not differ from the cartilage of the defect margins, the corresponding articular surface and the other cartilage surfaces. This leads to the conclusion that focal cartilage defects seen in degenerative joint damage are only one aspect of general joint degeneration.

[Knee-related Pain Problems during Pregnancy Correlate with an Increase in Body Weight. Results of a Prospective Study]

PURPOSE

This study aimed to evaluate the incidence of knee pain or the intensification of knee-related problems during pregnancy. We hypothesised that the occurrence of knee problems correlates with an increase in body weight during pregnancy.

METHODS

A total of 326 women (30(th)-40(th) week of pregnancy) were involved in this study. At onset of the pregnancy, the patients were 29.4 [95% CI 28.8-29.9] years of age. We asked all patients retrospectively about their anthropometric data at the beginning of pregnancy. All patients provided information about former knee problems, knee problems occurring after onset of pregnancy or any increase in these problems. These knee patients were re-evaluated 6 weeks after childbirth. At follow-up, the patients were asked about their knee problems and about their body weight.

RESULTS

At the beginning of pregnancy, the mean body weight was 68.0 kg (95% CI 64.4-69.6; range 41-117). The mean BMI of all patients was 24.5 kg/m² (25% CI 23.9-25.0; range 17.0-26.0). The absolute body weight increased by 13.8 kg (95% CI 13.2-1.5; range 3-38). A total of 24 patients (7.4%) reported new knee problems during pregnancy. 2 patients reported an increase in knee-related problems during pregnancy (0.6%). The incidence of knee-related problems (new cases and increase of problems n=26) was 26/326 or 7.6/100 pregnancies. In patients without knee problems, the pregnancy-related increase in the BMI (ΔBMI) was 4.8 kg/m² (95% CI 4.6-5.1, range 1.1-14.1). In cases with incident knee problems, the ΔBMI was 5.9 kg/m² (95% CI 4.9-6.9, range 2.1-11.8). The increase in body weight (Δbody weight) in patients without knee problems was 13.5 kg (95% CI 12.9-14.2, range 3-38). Patients with incident knee pain experienced a Δbody weight of 16.8 kg (95% CI 13.9-19.4, range 6-35). The differences in ΔBMI and Δbody weight were significant (p=0.009). A Δbody weight >20 kg was a significant risk factor for pregnancy-related knee pain significant risk factor pregnancy related pain. A total of 23 incident cases (92%) underwent a follow-up interview 6 weeks after parturition. At this time, a total of 6 patients (26.1%) had not experienced further knee problems, whereas persistent knee problems were reported in the remaining patients (73.9%). Patients without any knee complaints [body weight 72.5 kg (CI 95% 60.9-83.9)] tended to have a lower body weight at follow-up than patients with persistent knee pain [85.5 kg (CI 95% 71.8-99.1), p=0.162].

CONCLUSION

There is a body weight-associated increase in the incidence of functional knee pain in pregnant women. In about one-third of the cases, knee problems persist after pregnancy and are associated with a residual increase in body weight. Thus, we conclude that body weight is a potential risk factor for functional knee pain.

[Football as risk factor for a non-injury-related knee osteoarthritis - results from a systematic review and metaanalysis]

Aim and Hyopthesis: This systematic review and the metanalysis were performed to investigate the relation between football activity and the potential risk of knee osteoarthritis (possible occupational disease). It was hypothesised that soccer players suffer more than controls from knee osteoarthritis also in cases with an absence of documented major injuries.

METHODS

The review and the metaanalysis were performed accordingly to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. On 2014.02.01 a search was conducted within the medical databases PubMed, Medline, Cochrane, EMBASE und Web-of-Science. A total of 4,649 papers underwent a "Title-Abstract-Review". Finally 6 publications were included in the metaanaylsis.

RESULTS

There were no longitudinal community-based studies as well as no Cochrane Reviews regarding the risk of knee osteoarthritis in soccer players. After adjustment of major injuries of the knee, soccer players have a slightly increased risk for knee osteoarthritis: relative risk 1.3 (95 % CI 1.0 - 1.7); I(2) = 37.4 %; p = 0.002. In contrast, in studies without differentiation of injured and non-injured knees, the relative risk was significantly increased: 2.9 (95 % CI 2.0 - 4.1); I(2) = 56.3 %; p < 0.001.

CONCLUSIONS

Soccer players are a very heterogeneous group. The soccer player's knee undergoes different loadings including minor and major injuries. But the individual load also strongly depends on the player's status, his position within the football field and many other factors. In the absence of a major trauma the soccer player has only a slightly increased risk for the development of osteoarthritis. Thus we conclude that an injury in professional football does not fulfil the characteristics of an occupational disease.

[Focal cartilage defects within the medial knee compartment. predictors for osteoarthritis progression]

AIM

The aim of this study was to evaluate the progression of osteoarthritis (end-stage disease with a requirement for arthroplasty) in patients with focal cartilage defects of the medial knee compartment.

MATERIAL AND METHODS

Patients (n = 115) with focal cartilage lesions of the medial knee compartment underwent arthroscopy. The follow-up was performed 10 years after the operation to determine the rate of arthroplasty conversion and to evaluate associated factors.

RESULTS

In a total of 35 cases an arthroplasty was needed (30.4 %). The mean survival to arthroplasty was 93.2 (95 % CI 85.4-109.0) months. Cartilage defects within the femur and cartilage lesions within the patella and the lateral did not influence the OA progression. Among the significant risk factors for OA progression were higher patient age, female gender, overweight or obesity and severity of meniscal damage. The most important risk factor was the occurrence and the extent of tibial cartilage defects.

CONCLUSIONS

In the natural course, about 30 % of patients with focal cartilage defects of the medial knee compartment undergo rapid OA progression (arthroplasty as end-stage of the disease). There are general risk factors (age, female gender and obesity) but also local risk factors. Furthermore, tibial defects and the extent of meniscus loss influence the outcome significantly. These general and local factors should be more carefully estimated or addressed in future clinical and scientific work.

[The effect of arthroscopic debridement and conservative treatment in knee osteoarthritis: Results of a 5-year follow-up and literature review]

PURPOSE

This study is aimed to compare the effects of arthroscopic joint debridement over a 5-year period in a clearly defined patient population (only grade III knee osteoarthritis, history < 2 years).

MATERIAL AND METHODS

A total of 96 patients (50 male and 46 female) underwent arthroscopic knee debridement for knee OA. The main criteria for inclusion were osteoarthritis grade III (Kellgren-Lawrence score) and a maximal history of 2 years.

RESULTS

The subjective complaints and the knee-related quality of life were estimated by the KOOS (knee injury and osteoarthritis outcome score). The score increased significantly within the 1 to 3 rd year post operation. After this interval the mean points of the score declined. But after 5 years the KOOS was higher in comparison to the baseline dates. Patients who had undergone conservative treatment at baseline had a significantly different KOOS than patients in the arthroscopy group. Over time, patients in the arthroscopy group had fewer complaints than patients in the conservative treatment group. In both groups, the results decreased over time. A total of 17 patients (17.2 %) needed a conversion to total endoprothetic replacement. The mean time-interval between index operation and conversion was 56.6 (95 % CI 54.4 - 58.4) months.

CONCLUSIONS

In middle stages of knee OA, arthroscopic joint debridement can effectively reduce subjective complaints. Because this treatment does not stop the process of OA, the improvements decrease over time.

[Prevalence and distribution of knee cartilage lesions in sportspersons and non-sportspersons: results of a retrospective arthroscopic study]

AIM

This study was aimed to evaluate the correlation between sports activity and frequency and grad of non-traumatic knee cartilage lesions.

METHODS

A total of 868 patients (469 male and 399 female) who were suffering from knee pain (> 3 months) had undergone knee arthroscopy. The mean duration of history was 11.4 ± 11.5 (3 - 48) months. Criteria for exclusion were major knee injuries (e. g., ACL injuries). All cartilage lesions were classified according to the ICRS (International Cartilage Repair Society) guidelines and summarised with the semiquantitative WOAKS (Whole Organ Arthroscopic Knee Score).

RESULTS

There was a significant correlation between cartilage degeneration and age. Older female patients (63 to 85 years) demonstrated higher knee degenerations than male patients. The grade cartilage degeneration was higher in non-sportspersons (WOAKS = 13.5 ± 13.8) than in sportspersons (WOAKS = 7.1 ± 5.3), p < 0.001. Only in younger patients (17 to 34 years) was there no difference in the frequency of cartilage lesions in correlation to sports activity. A high-pivoting sport was significantly more frequently associated with cartilage degeneration in comparison to low-pivoting sports. Cartilage lesions most frequently occur within the mean bearing zones of the medial knee compartment. With regard to sports activity, no differences were observed in the distribution of cartilage lesions.

CONCLUSIONS

Sportspersons who suffer from knee pain without injury have significantly less cartilage lesions or, respectively, severe cartilage defects. Cartilage lesions mostly occur within the medial knee compartment without correlation to sports activity and sport type. Patients who are performing "high-pivoting" sports more frequently are suffering from severe cartilage lesions than "low-pivoting" sportspersons. For a final epidemiological estimation of any correlations between sports and cartilage damage, longitudinal MRI studies are needed.

[Evaluation of cartilage degeneration by near infrared spectroscopy (NIRS): methodical description and systematic literature review]

Damage to hyaline cartilage is the most important pathophysiological tool in the development of osteoarthritis. Cartilage lesions are the most frequent pathological findings during arthroscopic operations. Arthroscopies as well as magnetic resonance tomography are gold standards for detection of cartilage lesions. But the arthroscopic evaluation of cartilage lesions is descriptive and subjective only. The surgeon is able to differentiate between intact cartilage surface, softening, superficial or deep fissure or flake and finally a complete defect. In routine arthroscopy the grading mostly is made by use of different scores [e.g. ICRS (International Cartilage Repair Society), Outerbridge, Insall, Jäger-Wirth or others]. Because the arthroscopic evaluation is subjective the reliability of this method is poor. Spectroscopic methods are established for evaluation of different tissue diseases in different indications. NIRS (near infrared spectroscopy) has become an important method for medical diagnostics in the last years. NIR is very energy-rich and suitable for glass fibre transport without relevant reduction. Insofar this technology may be ideal for endoscopic procedures. Our systematic literature review reveals that NIRS is a sufficient method for an objective diagnosis of cartilage lesions. In the current work we demonstrate an NIRS-based device for intraoperative, real-time cartilage evaluation. Furthermore, we discuss the possible clinical consequences from such measurements.

[Metaanalysis for the evaluation of risk factors for carpal tunnel syndrome (CTS) Part I. General factors]

AIM

The expert committee of the German Ministry for Labour and Social Affairs suggested carpal tunnel syndrome (CTS) as an "occupational disease". This systematic literature review and metaanalysis was aimed at identifying associated and risk factors for CTS. Part I addresses the general factors and possible concurrent factors of CTS. These results may be helpful in later experts' reviews of the "occupational disease CTS".

METHODS

A systematic literature review was performed by examining papers in PubMed, Cochrane, EMBASE and Web of Science databases that were published on or before February 15th, 2011. A total of 87 studies (27 longitudinal and 60 cross-sectional) were included in this metaanalysis. The PRISMA (preferred reporting items for systematic reviews and metaanalyses) guidelines for performing a metaanalysis were strictly followed. All of the effect sizes were calculated using a random effects model.

RESULTS

The CTS prevalence in all studies independent of study type was 10.6 % (95 % CI 7.8-14.2). The crude incidence calculated from the longitudinal studies was 10.4 (95 % CI 8.9-11.9)/1000 person years. Female patients more frequently suffered from CTS [OR = 1.9 (95 % CI 1.6-2.2), p < 0.001]. The prevalence of CTS was correlated with an increase in age. The highest prevalence was observed in middle-aged patients (40 to 60 years old). Other significant CTS-associated factors were overweight or obesity [OR = 1.4 (95 % CI 1.3-1.6), p < 0.001]. CTS more frequently occurred in the dominant hand [OR = 1.8 (95 % CI 1.4-2.3), p < 0.001] and in persons of "non-white race" [OR = 1.6 (95 % CI 1.2-1.9), p < 0.001]. Furthermore, CTS was often associated with numerous other general diseases. Real risk factors (results from longitudinal studies) were the following: female gender [OR = 3.7 (95 % CI 2.6-5.2), p < 0.001], middle age [OR = 2.2 (95 % CI 0.9-4.9), p < 0.001], overweight or obesity [OR = 1.5 (95 % CI 1.1-1.9), p < 0.001], diabetes mellitus [OR = 5.3 (95 % CI 1.6-16.8), p < 0.001], and excessive alcohol abuse [OR = 2.3 (95 % CI 0.7-2.3), p < 0.001].

CONCLUSION

CTS is an extremely frequent disease. Independent of occupational burden, many patients are suffering from this frequent peripheral nervous compressive syndrome. These data will be essential in later experts' reviews of the "occupational disease CTS".

[Metaanalysis for the evaluation of risk factors for carpal tunnel syndrome (CTS) Part II. Occupational risk factors]

AIM

The expert committee of the German Ministry for Labour and Social Affairs suggested carpal tunnel syndrome (CTS) as an "occupational disease". This systematic literature review and metaanalysis was aimed at identifying associated and risk factors for CTS. Part II addresses the occupational factors of CTS.

MATERIAL AND METHOD

A systematic literature review was performed by examining papers in PubMed, Cochrane, EMBASE and Web of Science databases that were published on or before February 15th, 2011. A total of 87 studies (27 longitudinal and 60 cross-sectional) were included in this metaanalysis. The PRISMA (preferred reporting items for systematic reviews and metaanalyses) guidelines for performing a metaanalysis were strictly followed. All of the effect sizes were calculated using a random-effects model.

RESULTS

The prevalence of CTS in working populations [10.9 % (95 % CI 7.9-14 : 9)] was significantly higher than in the general population [8.2 % (95 % CI 2.3-25.1), p < 0.001]. Working people had a CTS incidence of 17.3 (95 % CI 14.5-20.1)/1,000 person years. In contrast, the crude incidence in the general population was 1.8 (95 % CI 1.4-2.2)/1.000 person years (p < 0.001). The heterogeneity of the different study designs made it impossible to detect concrete prevalence or incidence rates for specific job groups. However, "blue-collar work" was a significant risk factor for CTS [OR = 3.1 (95 % CI 1.9-5.3), p < 0.001]. Thus, it makes sense to evaluate concrete hand burdens. In numerous studies, some factors were associated with CTS: repetition [OR = 2.7 (95 % CI 1.8-39), p < 0.001), chronic wrist flexion [OR = 1.7 (95 % CI 1.0-2.6), p = 0.033], powerful grip [OR = 4.4 (95 % CI 1.4-13.6), p = 0.009], and chronic vibration load [OR = 2.6 (95 % CI 1.7-4.0)]. Primarily, combined hand loadings were estimated. For this evaluation, the hand activity level threshold limit values (HAL TLVs®) of the ACGIH (American Conference of Governmental Hygienists) were useful. Manual work in the 4th quartile of this score was significantly associated with the prevalence of CTS [OR = 2.9 (95 % CI 1.5-5.7), p = 0.001]. These score values were identified as a significant risk factor for occupational CTS.

CONCLUSION

It was impossible to define exact prevalences or incidences of CTS for specific job titles. However, it was possible to identify manual loadings with a significantly higher risk or association with CTS, including repetition, wrist flexion, powerful grip, and vibration. These loadings are usually combined during occupational work. Subsequent experts' reviews have to respect these complex hand loadings. It may be useful to use instruments, such as HAL TLVs®.

Knorpelregeneration nach valgisierender Tibiakopfosteotomie. Ergebnisse einer arthroskopischen Studie

Zielstellung: Die hohe Tibiakopfosteotomie (HTO) stellt ein etabliertes Verfahren bei der Behandlung unikompartimenteller medialer Gonarthrosen dar. Diese Studie wurde mit dem Ziel durchgeführt, eine mögliche Knorpelregeneration nach HTO in Beziehung zu den bei der Indexoperation angewandten arthroskopischen Knorpeltherapieverfahren zu untersuchen. Dazu wurden 1,5 Jahre nach medial öffnender HTO im Rahmen der Metallentfernung Kontrollarthroskopien durchgeführt. Material und Methode: Bei 135 Patienten (72 Männer und 63 Frauen; Altersmittelwert 48,8 Jahre) erfolgte nach knöcherner Konsolidierung einer Opening-Wedge-HTO (1,5 Jahre) die Metallentfernung mit gleichzeitiger Kontrollarthroskopie. Die Schwere der Knorpelschäden wurde durch das ICRS-Schema (International Cartilage Repair Society) bestimmt. Ergebnisse: Bei ursprünglich Grad III konnte im Bereich des medialen Femurkondyls in 40,4 % und im Bereich des medialen Tibiaplateaus in sogar 62,3 % eine verbesserte Knorpelqualität festgestellt werden. Dagegen kam es in 13,1 % im Bereich des MFC und 8,5 % im Bereich des TM zu einer Verschlechterung der ursprünglichen Grad-III-Läsionen in einen kompletten Defekt (Grad-IV-Schaden). Am besten schnitten dabei diejenigen Patienten ab, bei denen im Verlauf der Indexoperation eine Thermoablation durchgeführt wurde. Alle kompletten Defekte wurden anlässlich der Indexoperation durch Mikrofrakturierung nach Steadman behandelt. In knapp ⅔ der ehemaligen Defekte am MFC und in etwa ⅓ der ehemaligen TM-Defekte wurde dabei im Verlauf der Kontrollarthroskopie eine Auffüllung der ehemaligen Defektzone mit in der Hakenprobe stabilen Regeneraten nachgewiesen. Schlussfolgerungen: Die medial öffnende HTO in Kombination mit einer arthroskopischen Knorpeltherapie erbringt einerseits ein gutes klinisches Outcome und andererseits kommt es bei einem Teil der Patienten zu einer partiellen Regeneration der geschädigten Knorpelflächen. Ein Zusammenhang zwischen klinischem Outcome und der Knorpelregeneration konnte jedoch nicht sicher nachgewiesen werden. Nach unseren Untersuchungen ist die klinische Verbesserung in erster Linie auf die Wiederherstellung physiologischer Achsverhältnisse zurückzuführen. Inwieweit die Knorpelregeneration möglicherweise aber das Langzeitresultat beeinflusst, bleibt ungewiss.

[Therapy of acute ankle sprain: one-year results of primary conservative treatment]

INTRODUCTION AND AIM

Ankle sprains (supination-eversion injury) have a high incidence. Conservative treatment is generally the method of choice. This study is intended to evaluate the 1-year results of a standardised treatment protocol.

MATERIAL AND METHODS

A total of 416 patients who had suffered an ankle sprain were included into this study. All of them had undergone primary conservative treatment. A total of 66 of them (15.9 %) had undergone operative treatment within one year after injury. The indications for operation were persistent pain, swelling or persistent instability. In 33 patients an arthroscopy for evaluation of the joint and debridement was used. In the case of a persistent instability 22 ligament augmentations (Kuner periostal flap) and 11 peroneus tenodesis (Watson-Jones) were performed. The evaluation was done by using the AOFAS score ("Ankle Hindfoot Scale" of the American Orthopedic Foot and Ankle Society).

RESULTS

A 1-year follow-up was possible in 96.4 % of the patients. The mean AOFAS score was 77.1 ± 10.5 points after conservative treatment. Those patients who needed an arthroscopic debridement had a slightly better outcome (AOFAS score 79.5 ± 10.2 points). Patients who had undergone stabilisation operations tended to have the best outcome (p = 0.093). The AOFAS score was 79.6 ± 15.4 points in patients after periostal flap augmentation, respectively, 83.0 ± 7.4 points after peroneus tenodesis.

CONCLUSIONS

The results confirm the benefit of conservative treatment in acute ankle sprain. Even so about 15 - 20 % of the patients still suffer from persistent pain, swelling or instability. The indication for operative intervention should be made relatively broadly. Most of these patients profit from the operation. Above all, after ankle sprain patients need a continuous re-evaluation by a specialised centre during the first post-injury year.

[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.