Calcifying tendinitis is a relatively common disorder of the rotator cuff. For symptomatic patients, excision of the calcium deposits offers reliable pain relief. The arthroscopic technique is demanding. Arthroscopic localization of the deposit is frequently demanding. The technique described in this article facilitates the localization of calcium deposits based on preoperative ultrasonography. Knowing the exact topography of the deposit relative to the visible landmarks allows the surgeon to localize the site of the deposit from the intra-articular view. Probing the rotator cuff with a spinal needle and looking for calcific material at the tip of the needle is an important step in verifying the location of the deposit.

Arthroscopy↗

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Benign giant-cell tumor of the patellar ligament.

We report the symptoms, clinical findings, and treatment of a patient with an extra-articular benign giant-cell tumor of the patellar ligament. Between the years 1966 and 1996 no similar case has been found to be documented by a Medline search. On palpation, a soft, mobile lesion, the size of a pigeon's egg, was felt in the lateral region of the patellar ligament. There was no set of laboratory values to determine the diagnosis. In addition, there were no typical findings in diagnostic imaging procedures and it seems that the most important fact is that the clinician is aware of this type of synovial tumor. A clear diagnosis is only possible by means of a pathological investigation. The choice of therapy for giant-cell tumors is local excision. Arthroscopy is recommended exclusively for the diagnosis and therapy of a localized intra-articular giant-cell tumor.

Adult↗

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Hip arthroscopy without traction: In vivo anatomy of the peripheral hip joint cavity.

PURPOSE: To describe the in vivo anatomy of the peripheral compartment of the hip joint using a systematic sequence of examination without traction. TYPE OF STUDY: Case series. METHODS: We performed 35 hip arthroscopies without traction from an anterolateral portal in the supine position. Free draping and a good range of movement of the hip joint were used to relax parts of the capsule and increase the intra-articular volume of the area that was inspected. Each procedure was documented on a standard protocol including detailed information on technical features and normal and pathologic intra-articular findings. RESULTS: A comprehensive inspection of the peripheral compartment was obtained from the anterolateral portal. A systematic sequence of examination was developed separating the periphery of the hip joint into 7 areas: anterior neck area, medial neck area, medial head area, anterior head area, lateral head area, lateral neck area, and posterior area. The arthroscopic in vivo anatomy of each area is described. In 3 patients, 1 to 3 loose bodies were removed. In 1 patient with a synovial chondromatosis, 40 chondromas were retrieved. In osteoarthritis, impinging osteophytes were trimmed in 3 cases and partial synovectomy was performed in 10 patients. The following complications were observed: a temporary sensory deficit of the lateral femoral cutaneus nerve in 1 patient, scuffing of the anterior surface of the femoral head in 3 patients, detaching of an osteophyte in 1 patient, and partial tears of the anterior synovial fold in 10 patients. CONCLUSIONS: Arthroscopy without traction allows for a complete evaluation of hip anatomy without the loaded articular surfaces, the acetabular fossa, and the ligamentum teres. For a complete overview of both the central and peripheral part of the hip, traction is necessary for the central part.

Arthroscopy↗

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[Meniscus replacement with quadriceps tendon--a long-term analysis].

AIM: Early osteoarthritis of the knee is a common consequence ofA'complete meniscectomy. In order to prevent degenerative changes, meniscus replacement by autogenous quadriceps tendon was performed from 1986 until 1999 in 45 patients. In 29 patients, a reconstruction of the anterior cruciate ligament was done simultaneously. This study was intended to detect whether this meniscus replacement led to better subjective, clinical and radiological results in comparison to meniscectomised knees or meniscal allografts reported in the literature. METHODS: A standardised examination of the patients (4-17 years postoperatively, average 9 years) was carried out using the KOOS questionnaire, the IKDC examination form and a weight-bearing radiograph of the knee. RESULTS: 34 patients took part in the study. KOOS subgroups showed fair results for symptoms (25-96 points, average 65), butA'bad results for sports and quality of life (0-100, average 52; QoL 6-94, average 54). Clinical and radiological examination demonstrated on average stable knee joints without effusion (IKDC group A), but X-rays showed in most cases a clear or severe osteoarthritis of the knee (IKDC group C). Clinical and radiological findings demonstrated similar results in comparison with studies investigating results after meniscectomy without meniscus replacement. Concerning subjective results, meniscus replacement with quadriceps tendon was inferior to cryopreserved meniscal allografts. However, patients after meniscal allograft transplantation also show increasing degenerative changes of the respective joint in radiological follow-up studies. CONCLUSION: In the patient group studied here with pre-existing chondromalacia of the respective knee joint compartment and preoperative anterior instability, no advantage of meniscus replacement using quadriceps tendon over the normal course after meniscectomy could be proven. Therefore, this procedure cannot be generally recommended.

Adolescent↗

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[Significance of the hypoechoic area around the long biceps tendon in shoulder sonography--underlying pathology].

OBJECTIVE: The objective was to evaluate the sonographic sign of a hypoechoic area ("halo-sign") around the long biceps tendon as an equivalent of intraarticular effusion. METHODS: Part 1: Ten patients scheduled for shoulder arthroscopy underwent ultrasonography immediately before surgery. If there was no hypoechoic area around the long biceps tendon 30 ml of NaCl-solution (0.9%) were injected into the joint. After repetitive passive motion the patient underwent a second ultrasonography. Part 2: Ten consecutive patients with a hypoechoic area around the long biceps tendon underwent shoulder arthroscopy. During this procedure they were examined for intraarticular effusion. Patients with rheumatoid disease were excluded from the study. RESULTS: Part 1: In 9 of 10 patients a hypoechoic area around the long biceps tendon was induced by injection into the joint. The area was 1.07 +/- 0.13 cm2. In one case we could not induce the described phenomenon. Part 2: In all patients with a hypoechoic area around the long biceps tendon an intraarticular effusion was found at arthroscopy. CONCLUSION: A hypoechoic area around the long biceps tendon correlates with fluid in the synovial sheet and indicates effusion within the glenohumeral joint.

Arthroscopy↗

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[High tibial osteotomy--primary stability of several implants].

INTRODUCTION: High tibial osteotomy in varus knee has been performed for a long time. Several newer operation techniques have been established in recent years. We tested the primary stability of several of these techniques in vitro. MATERIAL AND METHODS: 10 human cadaveric fresh-frozen specimens were tested with a mean age of 61 years (range 50-72 years), and weight of 65 to 78 kg. The following implants were tested: One-third-tubular plate with cortical screw (AO, Synthes), blade plate with screws (Giebel's plate, Link), bone staples (osteotomy staples, Krackow staples, Smith & Nephew), external fixateur (Orthofix). The specimens were fixed in metal cylinders and then loaded in two different apparati: Shear forces were applied to the osteotomy site by hanging weights parallel to the osteotomy plane in a static-loading frame, and axial forces were applied by a materials testing machine (Zwick). Load displacement was recorded by inductive displacement transducers. RESULTS: The highest stability was achieved by the external fixateurs and the bone staples. Giebel's plate and the one third tubular plate were less stable. Receipt of the medial corticalis was decisive for primary stability of the implants. CONCLUSION: The clinical significance of the results is limited by the relevance of the protocol, which for practical reasons did not account for the soft tissue situation around the knee. Thus, primary stability of the tested devices was generally comparable as long as they were correctly implanted. It was found, that lateral distance of the osteotomized bone should not exceed 3 mm. If the medial cortical is sawed, another medial implant is necessary to ensure sufficient primary stability.

Aged↗

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[Improved radiological imaging of acetabular screw socket].

The improved radiological representation of the cementless acetabular screw-socket at two levels is of fundamental importance for the postoperative determination of position as well as for the judgement of an aseptic loosening. To improve the radiological representation two special radiographic techniques in the anterior-posterior as well as in the axial view have been examined on a human preparation of pelvis and have been scrutinized on a great number of clinical patients. The a.-p. radiography with twenty degrees cranio-caudal prone view in the sagittal plane and the axial radiography with forty-five degrees caudo-cranial prone view in the coronal plane shows the best and fewest overlayed representation of the screw-socket. The position of inclination and anteversion could have been directly determined out of these two radiographs. Malpositions of the screw-socket, especially with regard to the anteversion are easily identifiable due to the special axial radiographic technique. Overprojection of adjoining bone areas, which were possible should be considered at the judgment of the implant-bone-contact. Radiographic technical and positioning problems were not observed in patients. Out of these examinations the a.-p. radiography with twenty degrees cranio-caudal prone view in the sagittal plane and the axial radiography with forty-five degrees caudo-cranial prone view in the coronal plane could be recommended to the radiological diagnosis after implantations of hip prosthesis.

Acetabulum↗

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[Intertrochanteric flexion osteotomy and allo-arthroplasty in femur head necrosis. A comparative retrospective study].

Intertrochanteric flexion osteotomy and total hip arthroplasty are the most frequent operative treatments of advanced osteonecrosis of the femoral head in adults. In a retrospective study the postoperative results of intertrochanteric osteotomy and total hip arthroplasty were determined in 68 cases. The evaluation was based on the modified Harris-Hip-Score, the clinical examination and the radiological classification of the ARCO. The patients after osteotomy showed significantly worse subjective results. After osteotomy an increase of the stage of osteonecrosis was found in 73% of the patients. There was no correlation between clinical result and radiological stage of osteonecrosis. In spite of a better preoperative situation the results after osteotomy compared to hip arthroplasty were disappointing in many cases. The postoperative result did not depend on the preoperative stage of the osteonecrosis. The new classification system of the ARCO, which includes the very important MRI, proved to be very suitable and practicable. Based on our results it seems to be reasonable, to restrict the indication for intertrochanteric flexion osteotomy to cases of low stage osteonecrosis and carry out cementless total hip arthroplasty primarily in all others.

Adolescent↗

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[Dislocation of total hip endoprosthesis with special reference to various techniques].

1238 primary total hip replacements for arthritis were performed in our hospital from 1980 until 1988. 26 dislocations (2.1%) were registered during this period. No differences became obvious regarding age, sex, type of prosthesis and different concepts of postoperative treatment. After the posterior approach dislocations occurred in 18 (3.1%) of the cases, 8 dislocations (1.2%) were found after the transgluteal approach. The dislocation rate was significantly higher for the posterior approach. Derotation braces were not able to decrease the risk of redislocation. Most of the dislocations happened during the first postoperative week. The most frequent occasions were rotation of the operated leg while lying in bed and deep sitting positions. Performing the posterior approach for primary total hip arthroplasty the surgeon has to realize the higher dislocation rate.

Aged↗

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[Comparison of knee ligament scores and rating systems].

The results of the treatment of knee instabilities are evaluated by different scoring systems including subjective and/or objective criteria. Because of their number and their different criteria a comparison between the scoring systems is still a problem. The aim of this study was to analyze 14 different scoring-systems and prove the comparison of the commonly used rating scales. 116 patients with anterior or anterior-medial knee instabilities were followed up at least 2 years postoperatively. The evaluation was performed according to the criteria of the used rating-scales. The Lysholm I scoring system showed the highest mean total score (92 points). The scales that gave the highest correlation were the Cincinnati and ARPEGE scoring system (r = 0.97). The Lysholm I Scale and the Barrack Scale correlated least well (r = 0.711). This study documents that a transfer of results from one scoring system to another is not possible. A comparison between these scoring systems is only possible after adjusting the total points, the quality and the quantity of each criterion and component of the scoring system. This can done by using a standardized rating scale like the IKDC-score.

Activities of Daily Living↗

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[Basic equipment for arthroscopic knee surgery].

Five hundred arthroscopic operations were carried out with a 10-part hand-operated instrument set since January 1984. The most frequent operation was meniscectomy (84%), followed by removal of free bodies (18%) and division of plicae (7%). In four cases, there were instrument-dependent complications. By simulation of the surgical work on the joint in a suitable model, undesired, automatic movements of various instruments could be demonstrated. They depended on the respective principle of construction. The reliable grasping of meniscus tissue and free bodies was often a critical phase of the operation. Traction experiments on meniscus preparations showed that the arthroscopic forceps offered are frequently not equivalent to conventional surgical clamps. Instrument breaks were reconstructed in bending experiments. With some materials, a few bending cycles were sufficient in order to bring about the break. The experience obtained in our operations as well as in the laboratory experiments mentioned are described. Criteria for selection and use of hand-operated instruments for arthroscopic knee surgery are enunciated.

Arthroscopes↗

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[Extracorporeal shockwave therapy in tendionosis calcarea of the rotator cuff: comparison of different treatment protocols].

AIM OF THE STUDY: Extracorporeal shock wave therapy (ESWT) is a new therapeutic procedure for chronically painful calcifying tendinitis of the rotator cuff. The therapy may vary with the number of applied impulses or with impulse energy. Shock waves with an energy of 0.04 to 0.12 mJ/mm2 define low-dose ESWT, in contrast to high-dose ESWT (> 0.12 mJ/mm2). The aim of the study was to verify the hypothesis that either high-dose or low-dose ESWT could be effective if the total amount of applied energy was similar. METHOD: Fifty patients were assigned at random to 2 groups. The treatment consisted of 3 x 5000 low-dose impulses without anesthesia (group 1) and 1 x 5000 high-dose impulses with intravenous analgesia (group 2). The patients were examined at 6 weeks, 3 and 6 months after treatment. X-rays were performed at each visit. RESULTS: The Constant Score improved from 64.5 to 77.5 (group 1) and from 67.2 to 79.4 (group 2) before and 6 months after treatment (p < 0.05). The values on the visual analog scale which ranges from 0 (no pain) to 100 (maximal pain) improved from 76.8 to 48.8 (group 1) and from 75.4 to 45.6 (group 2) before and 6 months after treatment respectively. The final results for both Constant Score and visual analog scale were obtained after 3 months. X-rays showed a complete or subtotal calcific resorption in 8 (group 1, 32%) and 12 (group 2, 48%) patients. CONCLUSION: Extracorporeal shock wave therapy may be an alternative treatment of calcifying tendinitis of the shoulder. Both treatment protocols gave equivalent results.

Adult↗

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[Material properties of meniscus tissue and the effect of the menisci on the compression behavior of the knee joint].

Specimens of meniscus tissue were taken from different locations of the medial and lateral meniscus. They were tested to failure in the tensometer and force elongation diagrams were recorded. 28 meniscus specimens (14 medial, 14 lateral) gained at autopsy were available for testing. The posterior third of the medial meniscus and the middle third of the lateral meniscus were the strongest and stiffest parts of the meniscus. Yet local differences within one meniscus were only subtle. One clinical significance of these data is, that for replacement of the medial and lateral meniscus the same homogeneous material can be employed. Six tests under compression were carried out using six knee specimens gained at autopsy. Knee compression tests yielded different results after radial cutting of the meniscus, whereas partial meniscectomy had no effect on deformation and hysteresis. These biomechanical results support the concept of partial meniscectomy and preservation of the meniscal periphery. But they cannot be related to the problem of possible degenerative arthritis after partial meniscectomy.

Adult↗