[Reconstruction of acute anterior cruciate ligament rupture by suture and semitendinosus tendon augmentation.]

GOAL OF SURGERY

Restoration of normal knee function.

INDICATIONS

Acute avulsion of the anterior cruciate ligament (ACL) from its femoral origin.

CONTRAINDICATIONS

Mid substance and remote tears.

POSITIONING AND ANAESTHESIA

Supine. Knee flexed, hip bent to 30 degrees . General or regional anaesthesia.

SURGICAL TECHNIQUE

Step 1: Arthroscopy to confirm site of rupture, meniscus repair if necessary. Step 2: Mobilisation of semitendinosus tendon, left attached distally. Step 3: Mini-arthrotomy, securing of ACL stump with atraumatic suture. Step 4: Transfer of ST-tendon through 5 mm drill holes through tibial head and lateral femoral condyle. Step 5: Fixation of tendon and ACL-sutures with staple at the exit of the femoral drill hole.

POSTOPERATIVE MANAGEMENT

Knee orthosis for 6 weeks, CPM, physiotherapy. ROM day 0-2: 0-10-10 degrees ; day 3-11: 0-0-60 degrees , day 12-42: 0-0-90 degrees . Increase of weight bearing 10 kg/week from operation date. Bicycling and running permitted 3 months post-op. Full sport activity after muscle power has reached that of opposite side. LMW heparin until full weight bearing.

POSSIBLE COMPLICATIONS

Thrombosis. Embolism. Infection. Failure of reconstruction. Osteoarthritis.

RESULTS

During 1 year, 116 patients were operated. Follow-up after 42 to 57 months (average 52 months) included 95 patients (82%). Of these, 76 underwent full examination (average age 33 1/2 years, 20-49 years), 11 answered a questionnaire, 8 had suffered re-injury. Average Lysholm score was 92 points (+/-13). Tegner activity scale amounted to 7.2 points pre-injury, 7.1 points at follow-up. Anterior translation (KT 1000 arthrometer testing at 89 N) was identical to opposite side in 25 patients, less than 2 mm in 14, up to 4 mm in 19, up to 6 mm in 15, more that 6 mm in 3 patients. Pivot shift was negative or trace 73 times, and positive in 3 patients. ROM was full in 54 patients, 17 times the flexion was limited up to 10 degrees . Ten times extension lag was less than 5 degrees , and twice between 5 and 10 degrees .

Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial

BACKGROUND

Epidural neuroplasty seems to be one of the promising minimally invasive techniques for adhesiolysis in patients with chronic sciatica with or without low back pain. However, because no data exist from randomized studies the aim was to investigate whether this procedure is superior to conservative treatment with physiotherapy.

METHODS

A total of 99 patients with chronic low back pain were enrolled in this study and randomly assigned into either a group with physiotherapy (n = 52) or a second group undergoing epidural neuroplasty (n = 47). Patients were assessed before and 3, 6, and 12 months after treatment by a blinded investigator.

RESULTS

After 3 months, the visual analog scale (VAS) score for back and leg pain was significantly reduced in the epidural neuroplasty group, and the need for pain medication was reduced in both groups. Furthermore, the VAS for back and leg pain as well as the Oswestry disability score were significantly reduced until 12 months after the procedure in contrast to the group that received conservative treatment.

CONCLUSIONS

Epidural neuroplasty results in significant alleviation of pain and functional disability in patients with chronic low back pain and sciatica based on disc protrusion/prolapse or failed back surgery on a short-term basis as well as at 12 months of follow-up.

Long-term results of ventro-dorsal versus ventral instrumentation fusion in the treatment of spondylitis

This study examines prospectively the randomised, long-term, clinical and radiological results of the treatment of spondylitis patients by ventro-dorsal or ventral spine fusion. Group 1 consisted of 12 patients who (after ventral removal of the focus of infection and autologous bone grafting) were treated by dorsal instrumentation. Group 2 consisted of ten patients who, after similar ventral removal and bone interposition, were stabilised by ventral instrumentation. The patients prospectively underwent clinical and radiological studies. In addition, they were asked to fill in self-assessment questionnaires such as the short-form (SF)-36 health survey, the Oswestry questionnaire, and the visual analog scales (VAS). The postoperative follow-ups were at 6 months, 2 years and 5.4 years. It proved possible to demonstrate clinically that patients with an isolated ventral spondylodesis feel significantly better and experience significantly less pain in the area of spinal fusion than patients with ventro-dorsal fusion 2 and 5.4 years after the operation. Over a number of years a stable fusion can be achieved through either operation. Ventral stabilisation yields more advantages than dorsal instrumentation in the long term. These advantages result in a clinically smoother course after the operation. If, in the individual case, ventral instrumentation is feasible, this method should be used.

[Macerated human hip bone preparation as a substitute for fresh frozen preparations for testing the primary stability and frictional torques of cementless hip cups]

AIM

The aim of the study was to validate macerated human acetabuli as replacement for fresh frozen preparations for testing primary stability and the screwing in moments of cementless threaded hip cups.

METHOD

Three fresh frozen human pelvis were tested. One half of each pelvis was macerated whereas the other half was preserved as fresh frozen preparation. In the side of every pelvis the moments of screwing-in, the micromotions, the maximum expressing force and the maximum pull-out torque were determined.

RESULTS

The screwing in moments, the maximum expressing forces and the maximum pull-out torques did not change. The micromotions were reduced to half.

CONCLUSION

Considering the reduction of the micromotions, macerated human acetabuli are valid replacements for fresh frozen preparations for testing the primary stability and the screwing-in behaviour of screwed pans.

A prospective morphological study of facet joint integrity following intervertebral disc replacement with the CHARITE Artificial Disc

In degenerative disc disease (DDD), increased loading in the posterior column increases facet joint subchondral bone density and may lead to facet joint degeneration. While spinal fusion is commonly used to treat patients with symptomatic DDD, increased stress at the levels adjacent to fusion may accelerate facet joint and adjacent segment degeneration. Artificial disc replacements have been developed as an alternative to fusion. In this prospective study, the effects of disc replacement with the CHARITE Artificial Disc on facet joint loading and integrity were evaluated. Thirteen patients aged <50 years with symptomatic DDD were recruited. Computed tomography (CT) osteoabsorptiometry was performed prior to the implantation of the CHARITE Artificial Disc and six months after. With this technique, increases or decreases in facet joint loading and integrity are indicated by corresponding changes in subchondral bone density. Changes in the distribution of load alter the distribution of the areas of maximum bone density. Clinical outcome was also assessed at pre-operative and 6 and 12 month post-operative visits using the Visual Analogue Scale back and leg pain scores, the Oswestry Disability Index and the Short Form-36 (SF-36) questionnaire. The height of the intervertebral space at the operated level was monitored by lateral X-ray. Subchondral bone density was evaluated in the facet joints of all 13 patients at the operated level, 12 patients at the level above the operated segment, and five patients at the level below the operated segment. Quantitative measurements revealed no significant increases (> or =3%) in subchondral bone density of the facet joints at any level in any patient. Significant decreases (> or =3%) in subchondral bone density were measured at the operated level in 10/13 patients, at the level above the operated segment in 6/12 patients, and at the level below the operated segment in 3/5 patients. There were no changes in the distribution of the areas of maximum bone density in any of the studied facet joints at 6 months compared with pre-operative measurements. Clinical outcome scores were improved at 6 and 12 months compared with baseline. The mean intervertebral space height at the operated level was increased following implantation of the CHARITE Artificial Disc and was 1.8 times greater than the pre-operative height at both 6 and 12 months. In this study, replacement of degenerated intervertebral discs with the CHARITE Artificial Disc was not associated with increased loading of the facet joints at the operated or adjacent levels. Decreases in subchondral bone density may indicate reduced loading in the posterior column following disc replacement compared with loading in the pre-operative degenerated spine. Further study is required to establish the baseline for healthy subchondral bone density and to compare this baseline with long-term measurements in patients undergoing disc replacement.

Implantatentfernung bei ventro-dorsalen Spondylodesen - Ist eine Entfernung des dorsalen Implantats nach knöcherner Durchbauung sinnvoll?

BACKGROUND

The present study on spondylitis patients with anterio-posterior spondylodesis was carried out to get a recommendation whether material removal is necessary after osseous fusion.

METHODS

A total of 12 patients with spondylitis were operated on at the Orthopaedic Department of Ludwig-Maximilians-University Munich with posterior instrumentation after debridement and fusion with autologous bone transplant. In a prospective clinical investigation we examined our patients regarding clinical and radiological outcome preoperatively, 2 weeks, 12 months and 4.9 years after operation. We paid special attention on complications and loss of correction in leaving posterior instrumentation.

RESULTS

Compared with the advanced clinical signs of spondylitis, minor intra- and postoperative complications were seen. Two patients showed superficial wound infections with fistulization because of the posterior implants 3 years postoperatively. Both cases closed after revision and material removal without complications. 12 months and 4.9 years postoperatively the average loss of correction was constant 2 degrees .

CONCLUSION

Generally material removal of posterior spinal instruments results in a significant loss of correction in the spondylodesis segment. Our study shows, that persisting posterior instrumentation could prevent loss of correction. On the other hand we recommend material removal in case of spondylodesis after osseous fusion to prevent wound healing complications.

[New bone formation by extracorporeal shock waves. Dependence of induction on energy flux density]

BACKGROUND

The purpose of this study was to test the hypothesis that shock waves can induce new bone formation even without cortical fractures and periosteal detachment as suggested in the literature.

METHODS

Extracorporeal shock waves with energy flux densities between 0 mJ/mm(2) (sham treatment) and 1.2 mJ/mm(2) were applied in vivo to the distal femoral region of rabbits (1500 pulses at 1 Hz frequency each). Oxytetracycline was injected on days 5-9 and the animals were sacrificed on day 10. Sections of both femora of all animals were investigated with broadband fluorescence microscopy and contact microradiography for new periosteal and endosteal bone, periosteal detachment, cortical fractures, and trabecular bone with callus.

RESULTS

Shock waves with energy flux densities of 0.9 mJ/mm(2) and 1.2 mJ/mm(2) resulted in new periosteal bone formation in the presence of cortical fractures and periosteal detachment. After application of shock waves with energy flux density of 0.5 mJ/mm(2), clearly detectable signs of new periosteal bone formation were observed without cortical fractures or periosteal detachment.

CONCLUSIONS

The results of this study challenge the current view in the literature that the creation of cortical fractures and periosteal detachment are prerequisites for new bone formation mediated by extracorporeal shock waves.

Medium to long-term results with the cementless threaded Acetabular Munich II type cup

Compared to pressfit cups, little information exists about the results of screwed cups in hip arthroplasty. 51 cementless or hybrid (cemented stem) primary total hip replacements with a cementless corundium blasted titaniumn alloy threaded Aesculap Munich II type cup were examined with a mean follow up of 7.9 years. 23 of the patients were male and 28 patients were female. From these cups 22 were implanted on the right side and 29 on the left. The results were compared to 53 patients (28 male, 25 female, 29 right side, 24 left side) with the threaded Aesculap Munich I type cup, that has a smooth surface and a direct contact of bone with the polyethylene inlay. The mean follow up ws 10.2 years. The early and medium to long-term clinical and radiographic results show an encouraging improvement of the Merle d'Aubigné Score of the type II cup compared to the type I cup. Two of the Aesculap type Munich II cups had to be revised; four showed radiologic signs of loosening. In conclusion, the threaded Aesculap cup type Munich II seems to be a decisive advance in the development of threaded acetabular hip cups. The intermediate results exceed those from smooth-surface screwed rings and compare favourably with those from cemented cups and with those from cementless press-fit metal-backed cups.

Tunnel enlargement and changes in synovial fluid cytokine profile following anterior cruciate ligament reconstruction with patellar tendon and hamstring tendon autografts

There is growing evidence that cytokines such as tumor necrosis factor (TNF) alpha, interleukin (IL) 1beta, IL-6, bone morphogenetic proteins (BMP), and nitric oxide (NO) play an important role in the pathogenesis of bone tunnel enlargement following anterior cruciate ligament (ACL) reconstruction. Furthermore, the release of these mediators has been considered a possible reason for the higher incidence of bone tunnel enlargement following hamstring tendon (HST) than following patellar tendon (PT) ACL reconstruction observed in several studies. In this investigation synovial fluid samples from 13 patients were collected immediately before (24+/-7 days after ACL rupture) and 7 days after ACL surgery and values of TNF-alpha, IL-1beta, IL-6, NO, and BMP-2 were analyzed. Furthermore, the incidence of bone tunnel enlargement was assessed using radiographs 38+/-7 weeks after surgery. Six patients underwent autologous HST ACL reconstruction, and in seven patients an PT autograft was used. In the overall patient population there were significantly higher synovial fluid concentrations of IL-6 and BMP-2 postoperatively than preoperatively; TNF-alpha showed a trend towards lower postoperative levels while IL-1beta and NO remained unchanged. The concentrations of NO, TNF-alpha, and IL-6 found in the present study were clearly higher than normal values given in the literature. Assessment of bone tunnel enlargement revealed an average increase in tibial tunnel width of 28.4+/-3.1% with comparable values for HST and PT ACL reconstructions. There was no significant correlation between bone tunnel enlargement and postoperative synovial fluid concentrations of TNF-alpha, IL-1beta, IL-6, NO, and BMP-2. However, all patients with bone tunnel enlargement had higher postoperative concentrations of TNF-alpha, IL-6, and NO in the synovial fluid. There were no significant differences in concentrations between HST and PT groups. In conclusion, we observed an association between tibial bone tunnel enlargement and elevated synovial fluid concentrations of IL-6, TNF-alpha, and NO 7 days after ACL surgery indicating the potential involvement of these biological mediators in the pathogenesis of bone tunnel enlargement. However, there was no difference between HST and PT ACL reconstructions regarding synovial fluid contents of IL-6, TNF-alpha, IL-1beta, NO, and BMP-2, suggesting a comparable biological response between these autografts following their use in ACL reconstruction.

Long-term results of high tibial osteotomy for medial osteoarthritis of the knee

We reviewed retrospectively the results in patients who had undergone one hundred and four high tibial lateral osteotomies. The operations were all performed between 1985 and 1993. Each one of fifty men and forty nine women demonstrated a varus deformity of the knee with a coexistent medial osteoarthritis. Results were reviewed in 49 patients (62 knees) with an average follow-up of 10.2 years (range 6-14 years). Of the remaining 42 patients, 8 were lost to follow-up, 10 had died, and 24 were subsequently treated with total knee arthroplasty at an average 4.7 years after having had a high tibial osteotomy. Clinical results were evaluated using the Hospital for Special Surgery Score (HSS) and the Knee Society Score. Radiographs were systematically analysed to evaluate osteoarthritis and leg axis. Forty four (90 per cent) of the forty nine patients stated the results met their expectations and given the same circumstances, they would have the operation once again. In these patients the knee score results were excellent. The same patients had excellent HSS and Knee Society Scores. Five patients (10 per cent) had a poor result and twenty four patients were treated later by total knee arthroplasty because of pain. The following factors set these patients apart from those with more favorable results: previous arthroscopic debridement, obesity, lateral knee osteoarthritis, insufficient valgus correction, and an age of more than 55 years. High tibial valgus osteotomy provides good pain relief and improved function in carefully selected patients. Our results support this conclusion.

Quantitative Assessment of Angiogenesis in Murine Antigen-Induced Arthritis by Intravital Fluorescence Microscopy

Inhibition of angiogenesis might be a therapeutic approach to prevent joint destruction caused by the overgrowing synovial tissue during chronic joint inflammation. The aim of this study was to investigate angiogenesis in the knee joint of mice with antigen-induced arthritis (AIA) by means of intravital microscopy. In 14 mice (C57BL6/129Sv) intravital microscopic assessment was performed on day 8 after AIA induction in two groups (controls, AIA). Synovial tissue was investigated by intravital fluorescence microscopy using FITC-dextran (150 kD). Quantitative assessment of vessel density was performed according to the following categories: functional capillary density (FCD, vessels <10 microm in diameter), functional vessel density (FVD, vessels >10 microm) and FVD of vessels with angiogenic criteria (convoluted vessels, abrupt changes of diameter, vessels which are generated by sprouting and progressively pruned and remodelled). Microvessel count was performed using immunohistochemistry. There was no significant difference in FCD between the control group (337 +/- 9 cm/cm2; mean +/- SEM) and the AIA group (359 +/- 13 cm/cm2). The density of vessels larger than 10 microm diameter was significantly increased in animals with AIA (135 +/- 10 vs. 61 +/- 5 cm/cm2 in control). The density of blood vessels with angiogenic criteria was enhanced in arthritic animals (79 +/- 17 vs. 12 +/- 2 cm/cm2 in control). There was a significant increase in the microvessel count in arthritic animals (297 +/- 25 vs. 133 +/- 16 mm(-2) in control). These findings demonstrate that angiogenesis in murine AIA can be assessed quantitatively using intravital microscopy. Further studies will address antiangiogenic strategies in AIA.

[Chronic recurrent multifocal osteomyelitis]

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare, inflammatory, skeletal disease of unknown origin, which mainly affects children and adolescents in terms of cleido-spondylo-metaphysal skeletal inflammation. Only 10% of the patients are older than 20 years. To date, only about 200 cases have been reported in the literature. In the course of the disease, the initial radiological signs are osteolysis followed by sclerosis and hyperostosis in the end stage. The histological investigations reveal chronic inflammatory infiltrates with lymphocytes and hyperostosis. Although the prognosis of CRMO, to our current understanding, is self limiting, serious complications have been reported such as pathological fractures and compression fractures of the spine. A recently recommended therapy scheme is based on the administration of azithromycin combined with calcitonin. We present the case of a 25 year old female patient who has suffered from CRMO for 1.5 years with the cervical spine and the manubrium sterni being affected. The current state of diagnosis, therapy, and prognostic outlook of this rare disease are discussed.

Effects of ibandronate on inflammation in mouse antigen-induced arthritis

OBJECTIVE

To investigate the effects of ibandronate, a novel aminobisphosphonate, on inflammation as well as leukocyte-endothelial cell interaction in mouse antigen-induced arthritis (AiA).

MATERIAL AND TREATMENT

36 Balb/c mice were subcutaneously injected with 160 microg/kg of ibandronate once per day beginning at day 7 until day 13 after induction of AiA.

METHODS

The severity of arthritis was assessed by changes of the transverse knee joint diameter. For the intravital fluorescence microscopy measurements on day 14 after AiA induction, the patella tendon was partly resected to visualize the intraarticular synovial tissue of the knee joint. The number of rolling and adherent leukocytes as well as red blood cell (RBC) velocity and functional capillary density (FCD) were quantified in synovial microvessels. Furthermore, leukocyte infiltration in the synovium was determined in histological sections with an established score.

RESULTS

Both fractions of rolling leukocytes (p = 0.016) as well as number of extravasated leukocytes (p = 0.004) were enhanced in control animals treated with ibandronate in comparison to animals which received saline. Arthritic animals with and without ibandronate treatment revealed an increased FCD (p = 0.006, p = 0.008), enhanced number of rolling ( p = 0.002, p = 0.001) and adherent leukocytes (p = 0.009, p = 0.007) and greater swelling of the left knee joint (p = 0.002, p = 0.001) when compared to control animals. No significant differences between arthritic animals and arthritic animals treated with ibandronate were found in any of the parameters assessed including leukocyte adherence, FCD, histology, and knee joint swelling.

CONCLUSION

Ibandronate treatment of healthy mice was associated with an enhanced fraction of rolling leukocytes and increased numbers of extravasated leukocytes indicating a proinflammatory effect on the synovial microcirculation. In animals with a preexisting antigen-induced arthritis, however, ibandronate did not induce an exacerbation of joint inflammation and leukocyte adherence.

Resurfacing knee arthroplasty in patients with allergic sensitivity to metals

BACKGROUND

The problem of metal sensitivity (Ni, Cr, and Co) in arthroplasty is still unsolved. To prevent the risk of allergy in cases with proved metal allergy in an epicutaneous test, a Natural Knee total knee arthroplasty, made totally from titanium (Ti-6Al-4V) and polyethylene, can be implanted. The results of this device have to be compared to the results of normal knee arthroplasty designed with a femoral component out of CrCoNi alloy. The mechanical resistance of this alloy is much higher than that of titanium, and therefore it is the standard for the femoral components of most knee-resurfacing devices.

METHODS

Thirty-five patients with a titanium Natural Knee were examined retrospectively after a mean follow-up of 2 years and 5 months (range 6 months to 5 years and 4 months). In comparison, 36 patients with a Genesis-I knee with a CrCoNi alloy femoral component were studied after a mean follow-up of 2 years and 4 months (range 8 months to 6 years and 2 months).

RESULTS

In spite of the lower mechanical resistance of titanium, the Natural Knee showed better results (knee score 84.1 points, function score 77.7 points, HSS score 80.1 points, 82.9% excellent and good results) than the Genesis-I knee (knee score 80.6 points, function score 76.4 points, HSS score 76.4 points, 68.5% excellent and good results), although these differences had no statistical significance.

CONCLUSIONS

The titanium Natural Knee prosthesis has proven to be a reliable knee joint replacement in the medium term.

Irregular rotation and shift of computer-assisted femoral stem implantation in THA--an experimental study

INTRODUCTION

The two available computer-assisted surgery robotic systems consist of a preoperative planning computer workstation and an industrial robot with a high speed milling device. During the computed tomography (CT) scan of the hip and the ipsilateral knee for planning the hip arthroplasty, the patient's movements are registered by a bar that is fixed at the patient's leg along its axis. Despite the companies' claim that a high accuracy of implant position can be achieved by this method, misplacements of implants are reported in the literature.

MATERIALS AND METHODS

In an experimental study, a cadaver femoral bone was rotated during the CT scan strictly around this bar to simulate a rotational movement of the patient. Using the CT data, the planning of the hip stem and the following preparation of the femur by the robot was possible without detection of the patient's movements by the system. According to the system manual, the computer should stop the planning or give a warning in case of patient movement during the CT scan.

RESULTS

The postoperative CT scan of the cadaver femoral bone revealed a rotary deviation and a shift of the stem compared with the original planning, caused by the rotation during the CT scan.

CONCLUSION

We propose using a second bar during the CT scan to detect these movements and thus avoiding misplacement of the implant.

[Inflammatory responses to wear particles in vivo: a novel model in the murine knee joint]

Although it is now widely recognized that the inflammatory response to implant wear particles plays an important role in aseptic loosening of total joint replacements, the precise mechanisms of this process remain unclear. The aim of this study was to establish an animal model for the study of the adverse response to particulate wear debris and the effects on the synovial microcirculation as well as the leukocyte-endothelial cell interaction in the murine knee joint in vivo. Balb/c mice were injected with 50 microl of a 0.5-microm polystyrene particle suspension (0.1% v/v) into the knee joint. The severity of the inflammatory response was evaluated at days 1, 2, 3, 5, 7 (acute), 21 (intermediate), and 63 (chronic) after particle injection. Histological examination as well as assessment of the synovial microcirculation using intravital microscopy was performed. For the intravital microscopy measurements, the patella tendon was partially resected for visualization of the synovial tissue of the knee joint and the fluorescent markers FITC-dextran and rhodamine 6G were injected intravenously. There was a significantly enhanced leukocyte-endothelial cell interaction beginning at day 3 after particle injection with a maximum in the acute phase (days 5-7) and a subsequent decline in the intermediate (day 21) and chronic (day 63) phases. Functional capillary density was significantly increased from day 3 until day 21 after particle application. The histological examination showed an inflammatory reaction that complied widely with the temporal course of the microvascular parameters and resembled the histological appearance of the synovial-like membrane around loose joint prostheses. A novel model was established for the qualitative and quantitative investigation of the particle-induced inflammatory response in the joint environment. It was shown for the first time that there is a significantly enhanced leukocyte-endothelial cell interaction in the synovial tissue after intra-articular particle injection. This model seems to be suitable for further investigations, e.g., dealing with the biocompatibility of different particle materials.

Age-related changes of the glenoid labrum in normal shoulders

A growing number of labral changes are described in the literature. The purpose of this study was to evaluate the glenoid and labrum of normal shoulders at different ages and characterize any apparent age-dependent changes. We analyzed 32 normal cadaveric shoulders with a mean age of 57 years (range, 18-89 years). There were 22 male and 10 female cadavers, with 14 right and 18 left specimens. The shoulders were studied macroscopically, histologically, and radiologically. The radiologic evaluation consisted of an analysis of the subchondral mineralization of the glenoid with the use of computed tomographic osteoabsorptiometry. Macroscopically, there were no statistically significant differences among the age groups. Histopathologically, the labrum showed a significant qualitative and quantitative increase (P <.01) in lesions across all regions with increasing age. In younger individuals, lesions at the 12-o'clock position were the most prevalent, with the incidence increasing with age. The anterosuperior position was the region with the next highest prevalence. This was also the area of the highest stress distribution on the glenoid. Our studies demonstrated clear histopathologic changes of the glenoid labrum that are significantly age-related at specific sites. The earliest changes are seen close to the area of highest stress distribution of the glenoid, which could explain the progressive labral changes with increasing age. Arthroscopically detected changes of the glenoid labrum should be evaluated in the context of age-related changes in normal shoulders.

Long-term results after ankle arthrodesis: clinical, radiological, gait analytical aspects

In a retrospective study the results of operatively treated ankle joints were critically discussed. In a period from January 1, 1977 to December 31, 1994, a total of 35 arthrodeses were carried out. Seventeen patients were followed up clinically, radiologically and with a gait analysis. Not only the radiological surgical result was of interest, but also the heel-toe movement of the stiffened foot in the individually adapted orthopedic footwear compared to standard footwear. A significantly improved heel-toe movement was found in orthopedic shoes, although there is a reduction of movement in the hindfoot in the sagittal plane.

[The sublabral foramen. Congenital or an acquired variance?]

The sublabral foramen is considered to be a clinically asymptomatic, isolated variant of the anterior-superior capsulo-labral-complex. It may be observed during shoulder arthroscopy and may implicate problems in differential diagnosis of traumatic lesions. In an anatomic study on 89 macroscopically healthy shoulder specimens the age distribution and the incidence in relation to the varying shape of the glenoid as feasible factors of influence for a sublabral foramen (SF) were analyzed in order to elucidate the unknown pathogenesis of SF. In addition histologic sections of three SF samples were obtained. Mean age of the specimens with a sublabral foramen [n=20; 69 (37-84) years] was significantly higher (p=0.04) compared to samples without a sublabral foramen [n=69; 59 (18-94) years]. An increased incidence of a sublabral foramen in relation to a distinct shape of the glenoid could not be established although a prevalence of a glenoid with anterior notch was observed. The results indicate an age-related development of the sublabral foramen,thus in younger patients with an anterior-superior capsulolabral displacement local signs of trauma and involvement of the biceps anchor should be controlled before definitive diagnosis.

Subchondral mineralization patterns of the glenoid after tear of the supraspinatus

Clinical experience has shown that in many cases of rupture of the supraspinatus tendon the head of the humerus shifts upward against the acromion. This implicates alterations in the stress acting on the joint surface. Accordingly, this should be reflected by changes in the distribution of the subchondral mineralization on the glenoid. Computed tomography osteoabsorptiometry was used to evaluate the distribution patterns on the subchondral bone plate of the glenoid in 67 human shoulders. The position of the two most frequent density maxima was determined by a standard procedure. In macroscopically normal specimens (n = 24) every case had an anterosuperior density maximum and the majority (75%) also had a posterior positioned maximum. In some instances a third maximum, placed centrally (17%) or in an anteroinferior position (4%) was seen. In shoulders with a torn supraspinatus tendon (n = 43) a third density maximum frequently appeared in the center of the glenoid (42%); however, most notable was a significant change of the posterior maximum position toward central and superior. With increasing size of the tendon defect an extension of the shift of the posterior maximum (superiorly and centrally) was observed in contrast to the constant anterior maximum. The changes in the distribution of glenoid subchondral bone mineralization in shoulders with a supraspinatus tear must be regarded as a morphologic parameter for the altered long-term stress acting on the joint surface.

[Open surgical procedures in calcifying tendinitis of the shoulder - concomitant pathologies affect clinical outcome]

AIM OF THE STUDY

Open surgical removal of calcifications in chronic courses of calcifying tendinitis of the shoulder can be combined with acromioplasty. Independent of the surgical procedure not all patients achieve satisfactory surgical results. The aim of the study was to investigate whether preoperatively known epidemiologic, social, clinical and radiologic factors or intraoperative findings might influence the therapeutic outcome.

METHODS

Following diagnostic arthroscopy, open removal of the calcifications was done as an isolated procedure (group A, n = 12) or combined with open acromioplasty (group/B, n = 24). Follow-up was 33 months for both groups.

RESULTS

Clinical outcomes were comparable in both groups (Group A, 74.9 points; Group B 73.4 points, Constant-Murley score) and independent of gender, age, profession, duration of anamnesis, hospital-stay period, follow-up period, dominance of arm, preoperative Constant-Murley score, calcification morphology and size and acromial type. 20 patients in total achieved a clinical outcome of </= 75 points (Constant-Murley score). 12 of these demonstrated lesions of the rotator cuff and joint cartilage combined with synovialitis. In 6 patients an adverse preoperative Constant-Murley score or the wish to receive a pension was recorded.

CONCLUSION

Both surgical procedures lead to overall good and satisfactory clinical results. Below average clinical outcomes are associated with pathologic findings of the glenohumeral joints, adverse preoperative clinical situation or the wish to receive a pension.

The relation between primary osteoarthritis of the trapeziometacarpal joint and supernumerary slips of the abductor pollicis longus tendon

We have studied whether accessory abductor pollicis longus slips inserting into the thenar eminence or trapezium influence the incidence and severity of trapeziometacarpal joint osteoarthritis. The right first extensor compartment of 73 cadavers was dissected and trapeziometacarpal degeneration was graded macroscopically. The main abductor pollicis longus tendon which inserted at the metacarpal base was accompanied by supernumerary APL slips in 96% of cases. Thenar or trapezial slips occurred frequently but coexisted in only one case. The incidence of trapeziometacarpal arthritis was not influenced by the number of accessory slips or whether they inserted onto the thenar eminence or the trapezium.

Influence of extracorporeal shock-wave application on normal bone in an animal model in vivo. Scintigraphy, MRI and histopathology

There is little information about the effects of extracorporeal shock-wave application (ESWA) on normal bone physiology. We have therefore investigated the effects of ESWA on intact distal rabbit femora in vivo. The animals received 1500 shock-wave pulses each of different energy flux densities (EFD) on either the left or right femur or remained untreated. The effects were studied by bone scintigraphy, MRI and histopathological examination. Ten days after ESWA (0.5 mJ/mm2 and 0.9 mJ/mm2 EFD), local blood flow and bone metabolism were decreased, but were increased 28 days after ESWA (0.9 mJ/mm2). One day after ESWA with 0.9 mJ/mm2 EFD but not with 0.5 mJ/mm2, there were signs of soft-tissue oedema, epiperiosteal fluid and bone-marrow oedema on MRI. In addition, deposits of haemosiderin were found epiperiosteally and within the marrow cavity ten days after ESWA. We conclude that ESWA with both 0.5 mJ/mm2 and 0.9 mJ/mm2 EFD affected the normal bone physiology in the distal rabbit femur. Considerable damaging side-effects were observed with 0.9 mJ/mm2 EFD on periosteal soft tissue and tissue within the bone-marrow cavity.

Influence of extracorporeal shock-wave application on normal bone in an animal model in vivo

There is little information about the effects of extracorporeal shock-wave about application the effects (ESWA) of on normal bone physiology. We have therefore investigated the effects of ESWA on intact distal rabbit femora in vivo. The animals received 1500 shock-wave pulses each of different energy flux densities (EFD) on either the left or right femur or remained untreated. The effects were studied by bone scintigraphy, MRI and histopathological examination.

Ten days after ESWA (0.5 mJ/mm2 and 0.9 mJ/mm2 EFD), local blood flow and bone metabolism were decreased, but were increased 28 days after ESWA (0.9 mJ/mm2). One day after ESWA with 0.9 mJ/mm2 EFD but not with 0.5 mJ/mm2, there were signs of soft-tissue oedema, epiperiosteal fluid and bone-marrow oedema on MRI. In addition, deposits of haemosiderin were found epiperiosteally and within the marrow cavity ten days after ESWA.

We conclude that ESWA with both 0.5 mJ/mm2 and 0.9 mJ/mm2 EFD affected the normal bone physiology in the distal rabbit femur. Considerable damaging side-effects were observed with 0.9 mJ/mm2 EFD on periosteal soft tissue and tissue within the bone-marrow cavity.

Internal hemipelvectomy and reconstruction with a megaprosthesis

We treated nine consecutive patients by internal hemipelvectomy and reconstruction with custom-made megaprosthesis between 1990 and 1997. Four had a primary malignant bone or soft tissue tumour, one a recurrent benign giant cell tumour, three solitary metastatic bony lesions, and one a pelvic defect secondary to multiple revision procedures after total hip replacement. After a mean follow-up period of 62 (40-102) months five patients were still alive, including four of the eight patients with tumours. Three patients died as a result of the malignant disease, and one died of an infection related to the surgical treatment after 10-41 months. In two patients removal of the prosthesis was required due to infection, and six patients suffered various complications. One patient had an excellent outcome.

The value of desoxypyridinoline in the diagnostics of loosened arthroplasty

According to several reports in the last few years, desoxypyridinoline (Dpd) in urine increases significantly in cases of loosened arthroplasty. Therefore, this marker was suggested as useful in the diagnostics of implant loosening. In this study, the level of Dpd was determined in 69 patients with arthroplasty of the hip or the knee joint. Thirty-four of these patients received revision surgery following implant loosening. In 35 of these 69 patients, there were no clinical or radiological signs of loosening (control group). The mean age of the patients with loosened implants (22 women, 13 men) was 67.9 years and of the control group (22 women, 12 men) 66.9 years. In the group with arthroplastic loosening, as well as in the control group, 14 patients had increased levels of Dpd. There were 20 patients in the group with loosened arthroplasty and 19 patients in the control group that had normal levels of Dpd. The female patients had a mean Dpd level of 8.6 nmol/mmol creatinine (4.3-24 nmol/mmol creatinine) in the urine in cases of loosening and 10.1 nmol/mmol creatinine (2-33 nmol/mmol creatinine) in the control group. The male patients had a mean Dpd level of 7.8 nmol/mmol creatinine (3.2-19.2 nmol/mmol creatinine) in the urine in cases of loosening and 5.8 nmol/mmol creatinine (0.3-11.7 nmol/mmol creatinine) in the control group. In conclusion there was no significant increase in Dpd in patients with implant loosening compared with the control group. Furthermore, older patients often suffer from diseases causing increased bone resorption that may falsify the test results. We cannot confirm that Dpd is helpful in the diagnostics and screening of implant loosening.

On the impact of calcified deposits within the rotator cuff tendons in shoulders of patients with shoulder pain and dysfunction

We wanted to prove the hypothesis that calcified deposits within the rotator cuff tendons are merely an epiphenomenon of complex morphological alterations in the shoulders of patients with shoulder pain and dysfunction. The shoulders of 92 patients with calcified deposits within the rotator cuff tendons as noted on plain radiographs were investigated by means of magnetic resonance imaging (MRI; mean age of patient 51.1 years), as well as the shoulders of 28 age- and sex-matched patients with similar clinical symptoms but without any signs of such calcified deposits on plain radiographs. The MRI protocol comprised a coronal, oblique, T1-weighted, spin-echo sequence, a T2-weighted, turbo spin-echo sequence, a sagittal, oblique, T2-weighted, turbo spin-echo sequence, and an axial, T1-weighted, spin-echo sequence. Furthermore, a coronal, oblique, short tau-inversion recovery sequence and a gradient echo sequence were used. The results were compared with data from healthy, asymptomatic volunteers as reported in the literature. The MRI investigations showed no substantial differences between patients with or without calcified deposits within the rotator cuff tendons, but distinct differences between such patients and healthy, asymptomatic volunteers. For patients with shoulder pain, shoulder dysfunction, and calcified deposits within the rotator cuff tendons, these calcified deposits are most probably not the main cause of the clinical symptoms. Rather, it seems to be useful to consider the results of MRI investigations whenever planning therapeutic procedures for patients with shoulder pain and dysfunction, irrespective of whether or not there are signs of calcified deposits within the rotator cuff tendons on plain radiographs.

Pigmented villonodular synovitis. Review of 20 cases

OBJECTIVE

Pigmented villonodular synovitis (PVS) is a rare aggressive lesion. Inclusion of this disease in the differential diagnosis of rheumatoid arthritis can lead to early diagnosis and treatment. In this retrospective study we evaluated diagnostic procedures, therapies, and outcomes of PVS.

METHODS

Twenty surgically treated cases of PVS were evaluated: joint, 16; tenosynovial, 3; and bursa, one. The 20 patients had undergone the following surgeries: 4 total synovectomies, 2 subtotal synovectomies, eight arthroscopically assisted resections, 4 resections of extraarticular lesions, and 2 arthroplasties. The mean followup was 17.5 mo (1-54).

RESULTS

At diagnosis, pain was present in 19 of 20 cases. Joint swelling or a tumor was found in 11 cases, and 12 patients complained of repeated joint effusions. The mean duration of symptoms was 23.8 mo (range 1-144). Half the cases had a nodular pattern and the other half a diffuse pattern. The most common location of PVS was the knee (14 patients). Surgical treatment before admission did not always lead to an accurate diagnosis. For example, in 2 patients, arthroscopy did not reveal PVS. In 2 patients a soft tissue sarcoma was suggested. In 3 patients, the diagnosis was made incidentally with arthroscopy or arthroplasty. On radiographs, bone lesions were seen in 8 cases; in 13 of 17 cases the diagnosis was by magnetic resonance imaging (MRI). After surgery 17 patients stayed free of recurrence, 14 without symptoms. One patient who had an incidental diagnosis of PVS has a synovectomy planned as a second procedure. One patient awaits a second dorsal procedure after a ventral knee synovectomy. One patient shows recurrent disease 33 mo after resection of a nodular knee lesion.

CONCLUSION

PVS should be included in the differential diagnosis of any arthritis. MRI is the most effective diagnostic tool in identifying PVS. The treatment of PVS consists of surgical excision in sound tissue. A total synovectomy should be the treatment of choice in diffuse disease. From the literature, nonsurgical therapies, such as steroid injections, 90Y synoviorthesis, or external beam radiation, seem to be of benefit in selected patients.

Extracorporeal shock-wave therapy for chronic lateral tennis elbow--prediction of outcome by imaging

Today the clinical use of extracorporeal shockwave application (ESWA) for the treatment of lateral tennis elbow is hampered by the lack of results from randomized controlled trials and of predictive parameters of clinical outcome. The present prospective study aimed to provide the latter by means of magnetic resonance imaging (MRI). Twenty-three female and 19 male patients with unilateral chronic tennis elbow of the dominant site were clinically examined before and after repetitive low-energy ESWA. MRI was performed before ESWA to evaluate signal intensity changes or contrast enhancement of the common extensor tendon and the lateral epicondyle. After ESWA (mean follow-up period 18.6 months for all patients), clinical evaluation showed a significantly better mean clinical performance after ESWA than before treatment. Interestingly, male patients showed a significantly better mean clinical performance after ESWA than female patients, and male and female patients differed significantly in the signal intensity of the common extension tendon cross-section and tendon thickening on MRI. For female patients, MRI scans could be applied for predicting a positive clinical outcome of ESWA. This study reports the first indication of predictability of positive clinical outcome of the treatment of chronic lateral tennis elbow by ESWA using imaging prior to treatment. This may serve as an important step towards overcoming the therapeutic nihilism with respect to the non-operative management of this condition recently in the literature.

Oxaceprol, an atypical inhibitor of inflammation, reduces leukocyte adherence in mouse antigen-induced arthritis

Oxaceprol (N-acetyl-L-hydroxyproline), an atypical inhibitor of inflammation, is an established drug forjoint disease without serious side-effects. Recent studies have emphasized that oxaceprol has an effect on the microcirculation. Since the exact mechanism of action remains unclear, the aim of our study was to investigate the leukocyte-endothelial cell interactions in oxaceprol-treated mice with antigen-induced arthritis (AiA) using intravital microscopy. In our study, Balb/c mice were allocated to 4 groups (n 7, 8, 8, 8): 2 control groups with saline or oxaceprol and 2 groups of arthritic animals which received saline or oxaceprol (100 mg/kg twice a day intraperitoneally). The severity of arthritis was quantified by the transverse knee joint diameter. For the intravital fluorescence microscopy measurements on day 10 after inducing arthritis, the patella tendon was partily resected to visualize the intraarticular synovial tissue of the knee joint. The number of rolling and adherent leukocytes as well as RBC velocity and functional capillary density (FCD) were quantified in synovial microvessels. Furthermore, leukocyte infiltration was determined in the histological sections with an established score. No significant changes in mean arterial blood pressure or functional capillary density were found in any of the groups. However, the leukocyte rolling fraction and number of leukocytes adherent to the endothelium were increased in postcapillary venules of the synovium in arthritic animals (0.16 to 0.31, 78 cells/mm2 to 220 cells/mm2). In animals with AiA treated with oxaceprol, leukocyte adherence and swelling were significantly reduced in comparison to the arthritic animals treated with saline. Furthermore, the histological score showed less leukocyte infiltration in the oxaceprol treated arthritic animals. Thus, oxaceprol reduces leukocyte adherence in vivo and leukocyte infiltration in mouse AiA, indicating an effect on synovial microcirculation.

Exacerbation of antigen-induced arthritis in inducible nitric oxide synthase-deficient mice

OBJECTIVE

Inhibition of nitric oxide (NO) produced by inducible NO synthase (iNOS) is suggested to be beneficial in experimental arthritis. Although NO is important for the integrity of the microcirculation, the effects of inhibition of iNOS on the synovial microcirculation are not currently known. This study investigated the synovial microcirculation and leukocyte-endothelial cell interactions in iNOS-deficient mice with antigen-induced arthritis (AIA) and compared these findings with disease severity.

METHODS

Fourteen homozygous iNOS-/- and 14 iNOS+/+ mice were used. The severity of AIA was assessed by measuring knee joint swelling and by histologic scoring. The number of rolling and adherent leukocytes was quantitatively analyzed in synovial microvessels using intravital microscopy of intraarticular synovial tissue. Nitrite/nitrate concentrations were measured, and the expression of iNOS, E- and P-selectin, intercellular adhesion molecule 1, and vascular cell adhesion molecule 1 (VCAM-1) was assessed by immunohistochemistry.

RESULTS

In iNOS+/+ animals with AIA, the plasma concentration of nitrite/nitrate was increased 3-fold and iNOS expression was detected in cells of the joint. Swelling of the knee joint as well as leukocyte infiltration were enhanced in the iNOS-/- arthritic animals compared with iNOS+/+ mice with AIA. AIA-associated leukocyte-endothelial cell interaction in synovial postcapillary venules was more pronounced in iNOS-/-, compared with iNOS+/+, arthritic mice. A strong expression of P-selectin and VCAM-1 was observed in the iNOS-/- arthritic mice only.

CONCLUSION

These data suggest that NO production by iNOS in vivo has antiinflammatory effects in experimental arthritis, by mediating a reduction in leukocyte adhesion and infiltration.

Impaired tensile strength after shock-wave application in an animal model of tendon calcification

Extracorporeal shock-wave application facilitates dissolution of rotator cuff calcifications. Therefore, disappearance or disintegration of tendon calcifications by shock waves might be appropriate for any kind of tendon calcification. Here, shock waves with various energy flux densities were applied to the mineralized medial gastrocnemius tendon of turkeys as an animal model. After application of shock waves in vivo, with energy flux density of 0.6 mJ/mm(2), histologic examination and microradiography did not show dissolution or disintegration of tendon calcifications. After shock-wave application in vitro, even for energy flux density of 1.2 mJ/mm(2) neither dissolution nor disintegration of tendon calcifications were observed. Biomechanical testing revealed significant impairment of tensile strength following shock-wave application in vitro, with energy flux density of 1.2 mJ/mm(2), but not with 0.6 mJ/mm(2). These results are important for considerations of clinical extracorporeal shock-wave application on tendon calcifications, as well as on tendon ossifications.

Shockwave application in calcifying tendinitis of the shoulder--prediction of outcome by imaging

This prospective study examined 62 patients (65 shoulders) with chronic courses of calcifying tendinitis of the shoulder before and after low-energy extracorporeal shockwave application (ESWA) in order to identify variables associated with the outcome of this treatment. Before ESWA, radiographs and contrast-enhanced magnetic resonance imaging (MRI) of the affected shoulders were obtained in order to document the size and morphology of the calcifications and the contrast media reactions in areas of interest (deposit, synovia, bursae), respectively. In addition, a clinical evaluation was performed. After ESWA (mean follow-up 18.2 months), clinical evaluations of all 65 shoulders revealed an increase in the Constant score from 44% to 78% (p < 0.0001). While size (p = 0.61) and morphology (p = 0.7) of the deposits before ESWA were not associated with the clinical outcome, negative contrast reactions around the deposits (p) = 0.0001), synovia (p = 0.0049) and bursae (p < 0.01) were associated with improved clinical outcomes. After the total study group was divided into two groups, one with Constant scores > or = 75% (n = 43) and the other with scores < 75% (n = 22), the positive predictive value (ppv), specificity (sp) and sensitivity (se) were determined for the negative reaction around the deposit (ppv: 0.94; sp: 0.95; se: 0.38), synovia (ppv: 0.84; sp: 0.82; se: 0.49) and bursae (ppv: 0.86; sp: 0.86; se: 0.44). In 5 cases (7.7%), surgery of the affected shoulder during the follow-up period was performed. No major side-effects were seen in the study group. In conclusion, our results suggest that in patients with chronic calcifying tendinitis, the absence of contrast enhancement, especially around the deposit, is a strong predictive parameter of a positive clinical outcome of ESWA.

Extracorporeal shock wave application for chronic plantar fasciitis associated with heel spurs: prediction of outcome by magnetic resonance imaging

OBJECTIVE

To clarify morphologic features associated with the clinical outcome of extracorporeal shock wave application (ESWA) in chronic plantar fasciitis.

METHODS

In this prospective study 43 patients (48 heels) with chronic courses of plantar fasciitis were clinically examined before and after repetitive low energy ESWA. Standard radiographs of the affected heels were obtained before ESWA to document the existence of a calcaneal heel spur. Magnetic resonance imaging (MRI) was performed before ESWA to evaluate abnormalities of the plantar fascia, the surrounding soft tissue structures, and bone marrow edema of the calcaneus.

RESULTS

After ESWA (mean followup 19.3 mo), clinical evaluation of all 48 heels revealed a statistically significant decrease in the mean visual analog scale score from 74.5 to 25.4. Using the Roles and Maudsley score (RM), an established scoring system for categorizing results of treatment following ESWA for patients with plantar fasciitis, patients could be divided into 2 groups, i.e., satisfactory clinical outcome of ESWA (grades 1 and 2 by RM scale; n = 36 heels) and unsatisfactory outcome (grades 3 and 4 by RM scale; n = 12 heels). While thickness of plantar aponeurosis, soft tissue signal intensity changes, and soft tissue contrast medium uptake did not correlate with clinical outcome, the presence of a calcaneal bone marrow edema was highly predictive for satisfactory clinical outcome (positive predictive value 0.94, sensitivity 0.89, specificity 0.8).

CONCLUSION

This study indicates that in patients with chronic plantar fasciitis, the presence of calcaneal bone marrow edema on pretherapeutic MRI is a good predictive variable for a satisfactory clinical outcome of ESWA.

Tripled semitendinosus anterior cruciate ligament reconstruction with Endobutton fixation: a 2-3-year follow-up study of 35 patients

We evaluated the clinical outcome of tripled semitendinosus tendon ACL reconstruction with femoral Endobutton (Acufex, Smith&Nephew, Andover, MA) and tibial Suture Washer (Acufex, Smith&Nephew, Andover, MA) (n 29) or post screw fixation (n 6) in 35 patients on an average of 28 (20-37) months after surgery. On the basis of IKDC criteria, 22 patients showed a normal or nearly normal knee function and 25 patients had a KT 1000 maximal manual side-to-side difference of < or =5 mm at follow-up. Subjectively, 28 patients graded their knee function as normal or nearly normal. The average Lysholm score was 88 points, average OAK score 90 points and average modified HSS score 93 points. 19 patients reached their preinjury level of activity at follow-up. The postoperative Lachman test was < or =1+ in 24 patients and 24 patients also showed an absent pivot shift. Significant bone tunnel enlargement occurred in 26 patients on the femoral side and in 23 patients on the tibial side. We found no correlation between bone tunnel enlargement and clinical outcome. The clinical outcome of tripled semitendinosus tendon ACL reconstruction with Endobutton fixation on the femoral side was not entirely satisfactory. The procedure was associated with a high incidence of bone tunnel enlargement in this series.

Partial rupture of the distal biceps tendon

Partial rupture of the distal biceps tendon is a relatively rare event, and various degrees of partial tendon tears have been reported. In the current study four patients with partial atraumatic distal biceps tendon tears (mean age, 59 years; range, 40-82 years) are reported. In all four patients, a common clinical pattern emerged. Pain at the insertion of the distal biceps tendon in the radius unrelated to any traumatic event was the main symptom. In all patients the diagnosis was based on magnetic resonance imaging or computed tomography imaging. In three of four patients the partial rupture of the tendon caused a significant bursalike lesion. The typical appearance was a partially ruptured biceps tendon, with contrast enhancement signaling the degree of degeneration, tenosynovitis, and soft tissue swelling extending along the tendon semicircular to the proximal radius. In three patients, conservative treatment was successful. Only one patient needed surgery, with reinsertion of the tendon resulting in total functional recovery.

Malignant hemangiopericytoma of the bone

Hemangiopericytoma is a rare vascular tumor of pericyte origin with variable malignant potential. Very rarely, this tumor occurs as a primary bone lesion. We present a case of a highly malignant hemangiopericytoma of the proximal tibia. Current therapy consists of radical resection of the tumor with postoperative radiation therapy being recommended. Chemotherapy seems to be useful in disseminated disease. The prognosis correlates to the histological grading of the tumor. Early or late recurrence and distant metastases with fatal outcome, as shown in our case study, are not uncommon.

[A new resorbable bone-cartilage replacement transplant. Results of an animal experiment study]

Hyaline cartilage is thought to be unable to regenerate. All efforts so far--including autologous chondrocyte cell transplantation--to reconstruct cartilage defects in joints have not been totally convincing. However, mesenchymal cells are able to differentiate into chondrocytes under mechanical pressure conditions. In this study, an open porous resorbable two-layer "bioimplant" was constructed in which mechanical pressure was exerted onto mesenchymal cells when migrated into the open porous structure of the bioimplant. Differentiation of the cells into chondrocytes was thus induced. The bioimplants were implanted into the medial condyles of nine rabbits and left in place for eight or twelve weeks, respectively. In seven of these cases, cartilage formation was found, in contrary to the controls in which only connective tissue and bone had grown into the empty holes. The new bioimplants have proven their effectiveness in cartilage defect repair and might evolve in the future as a new alternative treatment of full thickness defects of joint surfaces.

Operative or conservative treatment of the acutely torn anterior cruciate ligament in middle-aged patients. A follow-up study of 133 patients between the ages of 40 and 59 years

In all, 133 patients with an acute rupture of the anterior cruciate ligament (ACL) were reviewed (aged 40 to 59 years). Average follow-up was 29 +/- 10 months. Thirty-one patients underwent conservative therapy, 35 patients were treated by primary suture, while in 67 the primary suture was augmented with the semitendinosus tendon. The patients with primary repair and semitendinosus tendon augmentation showed significantly better results according to OAK and Lysholm scores, the Lachman test, pivot-shift testing, and KT-1000 arthrometer measurements than those treated conservatively or with primary suture. The physical activity level was significantly higher in the patients with augmented ACL repair than in the conservatively treated patients. There was no significant difference between the patients with augmented ACL repair and conservative treatment in the assessment of range of motion, while the patients with primary suture had a significantly greater loss of flexion than those in the other two treatment groups. Increasing age was not found to have a negative effect on either operative or conservative treatment. The results indicate that patients between the ages of 40 and 59 years can be treated successfully by ACL surgery.

Chondromyxoid fibroma of bone

Chondromyxoid fibroma is a benign, although potentially aggressive tumor, with a cartilage-like matrix, accounting for approximately 1% of all bone tumors. It usually affects the metaphyseal region of long bones of patients in their first or second decade of life. An additional peak of incidence has been observed between 50 and 70 years of age. Three cases are presented here: 10-, 13-, and 52-year-old patients, with lesions in the proximal tibia, the proximal humerus, and the proximal femur, respectively. The literature is reviewed in terms of clinical behavior, diagnostic procedures, prognostic factors, treatment, and outcome. Preferred treatment is complete local excision with tumor-free margins. Intralesional curettage with or without local adjuvants shows a local recurrence rate of approximately 25%. Radiation therapy may be useful in nonresectable cases but bears the well documented risk of radiation-induced malignancies.

[Analgesic effect of low energy extracorporeal shock waves in tendinosis calcarea, epicondylitis humeri radialis and plantar fasciitis]

PURPOSE OF THE STUDY

Is there a pain reduction at the application site after extracorporeal shockwave application for tendinitis calcarea, epicondylitis radialis and plantar fasziitis?

METHODS

In a prospective study 85 patients were observed. Shockwave application was performed three or five times using low energies (0.09-0.18 ml/mm2). Before and after shockwave application pain was evaluated using SF-36 score and Visual Analog Scale (VAS).

RESULTS

After 5 months for all three indications a significant improvement of the pain situation could be reached. Patients with plantar fasziitis demonstrated the highest decrease of pain, followed by tendinosis calcarea and epicondylitis radialis. The number of applications had no influence to the clinical result of the ESWT.

RELEVANCE

In the present study the analgetic effect of ESWT after repeated low-energy application was described for the standard indications.

Castor oil decreases pain during extracorporeal shock wave application

In a prospective single-blind study the contact media ultrasound gel, vaseline and castor oil were examined for their effect on surface pain caused by extracorporeal shock waves used for tendinosis calcarea (n = 25), radiohumeral epicondylitis (n = 23) and plantar heel spur (n = 12). A total of 60 patients was divided into six groups. Using a Compact S shockwave source (Dornier MedTech), an energy flux density up to 0.12 mJ/mm2 was applied three times within 3 weeks. Independent of the diagnosis, there was a statistically significant influence of the contact medium on the intensity of application pain. In this comparison castor oil was best. For the diagnosis of tendinosis calcarea and plantar heel spur, castor oil was significantly better than the other two contact media, while for epicondylitis there was no significant difference. Castor oil was found to have an advantage over ultrasound jelly and vaseline in all indications used with regard to application pain. The positive effect of castor oil can be explained by its cavitation-free quality.

In vivo assessment of synovial microcirculation and leukocyte-endothelial cell interaction in mouse antigen-induced arthritis

OBJECTIVE

The microcirculation and leukocyte-endothelial cell interaction in synovial tissue of an inflamed joint are known to play a crucial role in the pathogenesis of rheumatoid arthritis. The aim of this study was to characterize the in vivo changes in the microvasculature and in leukocyte-endothelial cell interactions in the mouse synovial tissue using intravital fluorescence microscopy in three stages of antigen-induced arthritis. The expression of E- and P-selectin and ICAM-1 were also studied using immunohistochemistry.

METHODS

Antigen-induced arthritis (AiA) was produced in Balb/c mice. The severity of arthritis at three different phases was quantified using a clinical and histological score. For the intravital fluorescence microscopy measurements, the patella tendon was partially resected for visualization of the intraarticular synovial tissue of the knee joint. The number of rolling and adherent leukocytes, functional capillary density (FCD) and RBC velocity were quantitatively measured in synovial microvessels. Expression of ICAM-1, E- and P-selectin was assessed by immunohistochemistry.

RESULTS

There was a significant increase in the leukocyte rolling fraction in postcapillary venules in the acute phase of AiA (from 0.26 +/- 0.05 in controls to 0.45 +/- 0.04 8 d after AiA induction). The number of leukocytes adherent to the endothelium was significantly elevated in all phases of arthritis (from 121 +/- 27 in controls to 376 +/- 62 mm2 63 d after AiA-induction). Functional capillary density was significantly enhanced in the acute (332 +/- 15 cm/cm2) and intermediate phases (320 +/- 15 cm/cm2) compared to control values (227 +/- 15 cm/cm2). Arthritis resulted in a distinct increase in the expression of ICAM-1 on the synovial endothelium in all phases of AiA. E- and P-selectin expression were detected only in the acute phase.

CONCLUSION

Our model provides new insights into the microcirculatory changes which occur in the synovial tissue of an arthritic joint.