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Raeder C, Kämper M, Praetorius A, Tennler JS, Schoepp C. Metabolic, cognitive and neuromuscular responses to different multidirectional agility-like sprint protocols in elite female soccer players - a randomised crossover study. BMC Sports Sci Med Rehabil 2024; 16:64. [PMID: 38448940 PMCID: PMC10916312 DOI: 10.1186/s13102-024-00856-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE Resistance to fatigue is a key factor in injury prevention that needs to be considered in return-to-sport (RTS) scenarios, especially after severe knee ligament injuries. Fatigue should be induced under game-like conditions. The SpeedCourt (SC) is a movement platform for assessing multidirectional sprint performance, typical of game-sports, due to change-of-direction movements in response to a visual stimulus. Designing adequate fatigue protocols requires the suitable arrangement of several loading variables such as number of intervals, sprint distance or work/relief ratio (W:R). Therefore, this study analysed the acute fatigue effects of different SC protocols on metabolic load, cognitive function and neuromuscular performance. METHODS Eighteen female soccer players (mean ± SD; age: 23.1 ± 4.6 years) of the 1st German Division participated in this randomised, crossover study. Using a random allocation sequence, players completed four volume-equated protocols differing in W:R and sprint distance per interval (P1:12 × 30 m, W:R = 1:2 s; P2:12 × 30 m, W:R = 1:3 s; P3:18 × 20 m, W:R = 1:2 s; P4:18 × 20 m, W:R = 1:3 s). Pre- and post-exercise, metabolic load was measured per blood lactate concentration (BLaC), cognitive function per reaction time (RT), and neuromuscular performance including multiple rebound jumps (MRJ height, primary outcome variable; Reactive Strength Index, RSI) and 5 m sprint times (SP5). RESULTS Repeated-measures ANOVA revealed significant main time effects (p < .05) with improved performance post-exercise in RT (504 vs. 482 ms, d = 1.95), MRJ height (24.0 vs. 24.8 cm, d = 0.77), RSI (1.39 vs. 1.43, d = 0.52), and SP5 (1.19 vs. 1.17 s, d = 0.56). There was significant main time (p < .001) and time x protocol interaction effects in BLaC (p < .001). P1 induced higher BLaC values (4.52 ± 1.83 mmol/L) compared to P2 (3.79 ± 1.83 mmol/L; d = 0.74) and P4 (3.12 ± 1.83 mmol/L; d = 1.06), whereas P3 (4.23 ± 1.69 mmol/L) elicited higher BLaC values compared to P4 (d = 0.74). CONCLUSION All protocols caused an improved cognitive function and neuromuscular performance. The former may be related to enhanced noradrenergic activation or exercise specificity which induced an improved stimulus processing. The latter may be explained by a possible post-activation performance enhancement effect on jump and sprint performance. A shorter relief duration in W:R as opposed to sprint distance per interval produced higher BLaC values. The protocols may serve as reference data for improved RTS decision-making in elite female soccer players. TRIAL REGISTRATION Deutsches Register Klinischer Studien (DRKS), No.: DRKS00033496 , Registered 19. Februar 2024, Retrospectively Registered.
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Affiliation(s)
- Christian Raeder
- Department of Arthroscopy Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany.
| | - Meike Kämper
- Women´s Soccer Department, MSV Duisburg, Duisburg, Germany
| | - Arthur Praetorius
- Department of Arthroscopy Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
| | - Janina-Sophie Tennler
- Department of Arthroscopy Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
| | - Christian Schoepp
- Department of Arthroscopy Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
- Department of Trauma and Reconstructive Surgery, University Hospital Essen, Essen, Germany
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Häner M, Stoffels T, Guenther D, Pfeiffer T, Imhoff A, Herbort M, Stein T, Schoepp C, Akoto R, Höher J, Scheffler S, Stöhr A, Mehl J, Niederer D, Jung T, Kittl C, Eberle C, Vernacchia C, Ellermann A, Braun PJ, Krause M, Mengis N, Müller PE, Best R, Achtnich A, Petersen W. Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment. Knee Surg Sports Traumatol Arthrosc 2024; 32:223-234. [PMID: 38293720 DOI: 10.1002/ksa.12064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Martin Häner
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
| | | | - Daniel Guenther
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Thomas Pfeiffer
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Andreas Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | | | - Thomas Stein
- SPORTHOLOGICUM® Frankfurt am Main, Frankfurt, Germany
- Department of Sports Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Christian Schoepp
- Department of Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum, Duisburg, Germany
| | - Ralph Akoto
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | | | | | | | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Daniel Niederer
- Department of Movement and Training Science, Faculty of Humanities and Social Sciences, Institute of Sport Science, University of Wuppertal, Wuppertal, Germany
- Institute of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt, German
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | | | - Cara Vernacchia
- Department of Physical Medicine & Rehabilitation, Shirley Ryan Ability Lab, Chicago, Illinois, USA
- McGaw, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Philipp-Johannes Braun
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus, Berlin, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Natalie Mengis
- ARCUS Sports Clinic, Pforzheim, Germany
- KSA Aarau/Spital Zofingen, Zofingen, Switzerland
| | - Peter E Müller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
- Department of Sports Medicine and Orthopaedics, University of Tuebingen, Tuebingen, Germany
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Wolf Petersen
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
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Niederer D, Keller M, Wießmeier M, Vogt L, Stöhr A, Schüttler KF, Schoepp C, Petersen W, Pinggera L, Mengis N, Mehl J, Krause M, Janko M, Guenther D, Engeroff T, Ellermann A, Efe T, Best R, Groneberg DA, Behringer M, Stein T. The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction. J Sport Rehabil 2024; 33:88-98. [PMID: 38176405 DOI: 10.1123/jsr.2023-0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/20/2023] [Accepted: 10/22/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction. METHODS In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not. RESULTS At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers." CONCLUSIONS The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.
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Affiliation(s)
- Daniel Niederer
- Institute of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Max Wießmeier
- Department of Sports Medicine and Exercise Physiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Lutz Vogt
- Department of Sports Medicine and Exercise Physiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | | | - Christian Schoepp
- Department of Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg gGmbH, Duisburg, Germany
| | - Wolf Petersen
- Klinik für Orthopädie und Unfallchirurgie, Berlin, Germany
| | - Lucia Pinggera
- Department of Orthopaedic and Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
| | | | - Julian Mehl
- Department for Orthopaedic Sports Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Matthias Krause
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maren Janko
- Department of Trauma, Hand, and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Daniel Guenther
- Department of Orthopedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Witten, Germany
| | - Tobias Engeroff
- Division Health and Performance, Goethe University Frankfurt, Institute of Occupational, Social and Environmental Medicine, Frankfurt am Main, Germany
| | | | - Turgay Efe
- Orthopaedicum Lich Giessen, Lich, Germany
| | - Raymond Best
- Department of Orthopaedic and Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
| | - David A Groneberg
- Institute of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Michael Behringer
- Department of Sports Medicine and Exercise Physiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Thomas Stein
- Department of Sports Medicine and Exercise Physiology, Goethe University Frankfurt, Frankfurt am Main, Germany
- SPORTHOLOGICUM Frankfurt-Center for Sport and Joint injuries, Frankfurt am Main, Germany
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Gensior TJ, Mester B, Achtnich A, Winkler PW, Henkelmann R, Hepp P, Glaab R, Krause M, Frosch KH, Zellner J, Schoepp C. Anatomic repair and ligament bracing as an alternative treatment option for acute combined PCL injuries involving the posteromedial or posterolateral corner-results of a multicentre study. Arch Orthop Trauma Surg 2023; 143:7123-7132. [PMID: 37691046 PMCID: PMC10635947 DOI: 10.1007/s00402-023-05015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/24/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. MATERIALS & METHODS N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. RESULTS N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). CONCLUSIONS One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Tobias J Gensior
- OPND Clinic Neuss-Düsseldorf, Neuss, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Bastian Mester
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany.
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland.
| | - Andrea Achtnich
- Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Philipp W Winkler
- Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria
| | - Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Pierre Hepp
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Richard Glaab
- Department of Traumatology, Cantonal Hospital Aarau, Aarau, Switzerland
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Clinic Hamburg, Hamburg, Germany
| | - Johannes Zellner
- Sporthopaedicum Regensburg, Regensburg, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Christian Schoepp
- Clinic for Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Clinic Duisburg, Duisburg, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
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Mester B, Kröpil P, Ohmann T, Schleich C, Güthoff C, Praetorius A, Dudda M, Schoepp C. The influence of distribution, severity and volume of posttraumatic bone bruise on functional outcome after ACL reconstruction for isolated ACL injuries. Arch Orthop Trauma Surg 2023; 143:6261-6272. [PMID: 37269350 PMCID: PMC10491520 DOI: 10.1007/s00402-023-04907-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 05/06/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Posttraumatic MRI of ACL tears show a high prevalence of bone bruise (BB) without macroscopic proof of chondral damage. Controversial results are described concerning the association between BB and outcome after ACL tear. Aim of this study is to evaluate the influence of distribution, severity and volume of BB in isolated ACL injuries on function, quality of life and muscle strength following ACL reconstruction (ACLR). MATERIALS AND METHODS MRI of n = 122 patients treated by ACLR without concomitant pathologies were evaluated. BB was differentiated by four localizations: medial/lateral femoral condyle (MFC/LFC) and medial/lateral tibial plateau (MTP/LTP). Severity was graded according to Costa-Paz. BB volumes of n = 46 patients were quantified (software-assisted volumetry). Outcome was measured by Lysholm Score (LS), Tegner Activity Scale (TAS), IKDC, isokinetics and SF-36. Measurements were conducted preoperatively (t0), 6 weeks (t1), 26 weeks (t2) and 52 weeks (t3) after ACLR. RESULTS The prevalence of BB was 91.8%. LTP was present in 91.8%, LFC 64.8%, MTP 49.2% and MFC 28.7%. 18.9% were classified Costa-Paz I, 58.2% II and 14.8% III. Total BB volume was 21.84 ± 15.27 cm3, the highest value for LTP (14.31 ± 9.93 cm3). LS/TAS/IKDC/SF-36/isokinetics improved significantly between t0-t3 (p < 0.001). Distribution, severity and volume had no influence on LS/TAS/IKDC/SF-36/isokinetics (n.s.). CONCLUSIONS No impact of BB after ACLR on function, quality of life and objective muscle strength was shown, unaffected by concomitant pathologies. Previous data regarding prevalence and distribution is confirmed. These results help surgeons counselling patients regarding the interpretation of extensive BB findings. Long-time follow-up studies are mandatory to evaluate an impact of BB on knee function due to secondary arthritis.
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Affiliation(s)
- Bastian Mester
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
| | - Patric Kröpil
- Department for Radiology, BG Klinikum Duisburg, Großenbaumer Allee 250, 47249, Duisburg, Germany
| | - Tobias Ohmann
- Research Department, BG Klinikum Duisburg, Großenbaumer Allee 250, 47249, Duisburg, Germany
| | - Christoph Schleich
- Department for Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Claas Güthoff
- Centre for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - Arthur Praetorius
- Department for Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Großenbaumer Allee 250, 47249, Duisburg, Germany
| | - Marcel Dudda
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
- Department for Orthopedics and Trauma Surgery, BG Klinikum Duisburg, Großenbaumer Allee 250, 47249, Duisburg, Germany
| | - Christian Schoepp
- Department for Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Großenbaumer Allee 250, 47249, Duisburg, Germany
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Petersen W, Guenther D, Imhoff AB, Herbort M, Stein T, Schoepp C, Akoto R, Höher J, Scheffler S, Stoehr A, Stoffels T, Häner M, Hees T, Mehl J, Ellermann A, Krause M, Mengis N, Eberle C, Müller PE, Best R, Lutz PM, Achtnich A. Management after acute rupture of the anterior cruciate ligament (ACL). Part 1: ACL reconstruction has a protective effect on secondary meniscus and cartilage lesions. Knee Surg Sports Traumatol Arthrosc 2023; 31:1665-1674. [PMID: 35445329 PMCID: PMC10089999 DOI: 10.1007/s00167-022-06960-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of this consensus project was to validate which endogenous and exogenous factors contribute to the development of post-traumatic osteoarthritis and to what extent ACL (anterior cruciate ligament) reconstruction can prevent secondary damage to the knee joint. Based on these findings, an algorithm for the management after ACL rupture should be established. METHODS The consensus project was initiated by the Ligament Injuries Committee of the German Knee Society (Deutsche Kniegesellschaft, DKG). A modified Delphi process was used to answer scientific questions. This process was based on key topic complexes previously formed during an initial face-to-face meeting of the steering group with the expert group. For each key topic, a comprehensive review of available literature was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Consensus was defined a-priori as eighty percent agreement. RESULTS Of the 17 final statements, 15 achieved consensus, and 2 have not reached consensus. Results of the consensus were summarized in an algorithm for the management after ACL rupture (infographic/Fig. 2). CONCLUSION This consensus process has shown that the development of post-traumatic osteoarthritis is a complex multifactorial process. Exogenous (primary and secondary meniscus lesions) and endogenous factors (varus deformity) play a decisive role. Due to the complex interplay of these factors, an ACL reconstruction cannot always halt post-traumatic osteoarthritis of the knee. However, there is evidence that ACL reconstruction can prevent secondary joint damage such as meniscus lesions and that the success of meniscus repair is higher with simultaneous ACL reconstruction. Therefore, we recommend ACL reconstruction in case of a combined injury of the ACL and a meniscus lesion which is suitable for repair. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Wolf Petersen
- Sportsclinic Berlin, Department of Orthopedics, Martin Luther Hospital, Berlin-Grunewald, Caspar-Theyß-Straße 27-31, 14193, Berlin, Germany
| | - Daniel Guenther
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine Cologne Merheim Medical Center (Witten/Herdecke University), Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Andreas B Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Mirco Herbort
- OCM Clinic Munich, Steinerstrasse 6, 81369, Munich, Germany
| | - Thomas Stein
- SPORTHOLOGICUM® Frankfurt Am Main, Siesmayerstraße 44, 60323, Frankfurt am Main, Germany
- Department of Sports Medicine, Goethe University Frankfurt, Ginnheimer Landstraße 39, 60487, Frankfurt am Main, Germany
| | - Christian Schoepp
- Department of Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum, Duisburg gGmbH, Großenbaumer Allee 250, 47249, Duisburg, Germany
| | - Ralph Akoto
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Jürgen Höher
- SPORTSCLINIC COLOGNE, Ostmerheimer Str. 200, 51109, Köln, Germany
| | - Sven Scheffler
- Sporthopaedicum Berlin, Bismarckstrasse 45-47, 10627, Berlin, Germany
| | - Amelie Stoehr
- OCM Clinic Munich, Steinerstrasse 6, 81369, Munich, Germany
| | | | - Martin Häner
- Sportsclinic Berlin, Department of Orthopedics, Martin Luther Hospital, Berlin-Grunewald, Caspar-Theyß-Straße 27-31, 14193, Berlin, Germany
| | - Tilman Hees
- Sportsclinic Berlin, Department of Orthopedics, Martin Luther Hospital, Berlin-Grunewald, Caspar-Theyß-Straße 27-31, 14193, Berlin, Germany
| | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Andree Ellermann
- ARCUS Sports Clinic, Rastatter Str. 17-19, 75179, Pforzheim, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Natalie Mengis
- ARCUS Sports Clinic, Rastatter Str. 17-19, 75179, Pforzheim, Germany
| | - Christian Eberle
- ARCUS Sports Clinic, Rastatter Str. 17-19, 75179, Pforzheim, Germany
| | - Peter E Müller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart, Taubenheimstraße 8, 70372, Stuttgart, Germany
- Department of Sports Medicine and Orthopaedics, University of Tuebingen, Hoppe Seyler Strasse 5, 72074, Tuebingen, Germany
| | - Patricia M Lutz
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
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Tennler J, Raeder C, Praetorius A, Ohmann T, Schoepp C. Effectiveness of the SMART training intervention on ankle joint function in patients with first-time acute lateral ankle sprain: study protocol for a randomized controlled trial. Trials 2023; 24:162. [PMID: 36869403 PMCID: PMC9985260 DOI: 10.1186/s13063-023-07195-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/20/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND The lateral ankle sprain (LAS) is the most common injury in the field of everyday and sports-related activities. There is a high rate of patients with LAS who will develop chronic ankle instability (CAI). A possible explanation for this high rate is an insufficient rehabilitation and/or a premature return to intense exercise and workloads. Currently, there are general rehabilitation guidelines for LAS but there is a lack of standardized evidenced-based rehabilitation concepts for LAS, which effectively reduce the high CAI rate. The primary aim of the study is to investigate the effectiveness of a 6-week sensorimotor training intervention (SMART-Treatment, SMART) in contrast to standard therapy (Normal Treatment, NORMT) after an acute LAS on perceived ankle joint function. METHODS This study will be a prospective, single-center, interventional randomized controlled trial with an active control group. Patients (14-41 years) with an acute LAS and a MRI confirmed lesion or rupture of at least one ankle ligament will be included. Exclusion criteria are acute concomitant injuries of the ankle, pre-injuries of the ankle, serious lower-extremity injuries of the last 6 months, lower-extremity surgery, and neurological diseases. The primary outcome measure will be the Cumberland Ankle Instability Tool (CAIT). Secondary outcomes include the Foot and Ankle Ability Measurement (FAAM), isokinetic and isometric strength diagnostics, joint repositioning sense, range of motion, measurements of postural control, gait and run analysis, and jump analysis. This protocol will follow the SPIRIT guidance. DISCUSSION Current management of LAS rehabilitation lacks since there is a high rate of patients developing a CAI. It has been shown that exercise therapy improves ankle function in acute LAS as well as in patients with CAI. It is further recommended to address specific impairment domains in ankle rehabilitation. However, empirical data for such a holistic treatment algorithm is missing. Therefore, this study has the potential to improve the healthcare for LAS patients and might be used for a future standardized evidence-based rehabilitation concept. TRIAL REGISTRATION "Prospectively registered" ISRCTN - ISRCTN13640422 17/11/2021; DRKS (German Clinical Trials Register) - DRKS00026049.
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Affiliation(s)
- Janina Tennler
- Department for Arthroscopic Surgery, Sports Traumatology & Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany.
| | - Christian Raeder
- Department for Arthroscopic Surgery, Sports Traumatology & Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
| | - Arthur Praetorius
- Department for Arthroscopic Surgery, Sports Traumatology & Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
| | - Tobias Ohmann
- Research Department, BG Klinikum Duisburg, Duisburg, Germany
| | - Christian Schoepp
- Department for Arthroscopic Surgery, Sports Traumatology & Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany.,Department of Trauma and Reconstructive Surgery, University Hospital, Essen, Germany
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Niederer D, Mengis N, Wießmeier M, Keller M, Petersen W, Ellermann A, Drenck T, Schoepp C, Stöhr A, Fischer A, Achtnich A, Best R, Pinggera L, Krause M, Guenther D, Janko M, Kittl C, Efe T, Schüttler KF, Vogt L, Behringer M, Stein T. Contributors to self-report motor function after anterior cruciate ligament reconstruction. Sci Rep 2023; 13:3073. [PMID: 36813953 PMCID: PMC9947165 DOI: 10.1038/s41598-023-30291-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 02/21/2023] [Indexed: 02/24/2023] Open
Abstract
Numerous functional factors may interactively contribute to the course of self-report functional abilities after anterior cruciate ligament (ACL)-reconstruction. This study purposes to identify these predictors using exploratory moderation-mediation models in a cohort study design. Adults with post unilateral ACL reconstruction (hamstring graft) status and who were aiming to return to their pre-injury type and level of sport were included. Our dependent variables were self-reported function, as assessed by the the KOOS subscales sport (SPORT), and activities of daily living (ADL). The independent variables assessed were the KOOS subscale pain and the time since reconstruction [days]. All other variables (sociodemographic, injury-, surgery-, rehabilitation-specific, kinesiophobia (Tampa Scale of Kinesiophobia), and the presence or absence of COVID-19-associated restrictions) were further considered as moderators, mediators, or co-variates. Data from 203 participants (mean 26 years, SD 5 years) were finally modelled. Total variance explanation was 59% (KOOS-SPORT) and 47% (KOOS-ADL). In the initial rehabilitation phase (< 2 weeks after reconstruction), pain was the strongest contributor to self-report function (KOOS-SPORT: coefficient: 0.89; 95%-confidence-interval: 0.51 to 1.2 / KOOS-ADL: 1.1; 0.95 to 1.3). In the early phase (2-6 weeks after reconstruction), time since reconstruction [days] was the major contributor (KOOS-SPORT: 1.1; 0.14 to 2.1 / KOOS-ADL: 1.2; 0.43 to 2.0). Starting with the mid-phases of the rehabilitation, self-report function was no longer explicitly impacted by one or more contributors. The amount of rehabilitation [minutes] is affected by COVID-19-associated restrictions (pre-versus-post: - 672; - 1264 to - 80 for SPORT / - 633; - 1222 to - 45 for ADL) and by the pre-injury activity scale (280; 103 to 455 / 264; 90 to 438). Other hypothesised contributors such as sex/gender or age were not found to mediate the time or pain, rehabilitation dose and self-report function triangle. When self-report function is rated after an ACL reconstruction, the rehabilitation phases (early, mid, late), the potentially COVID-19-associated rehabilitation limitations, and pain intensity should also be considered. As, for example, pain is the strongest contributor to function in the early rehabilitation phase, focussing on the value of the self-report function only may, consequently, not be sufficient to rate bias-free function.
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Affiliation(s)
- Daniel Niederer
- Institute of Occupational, Social and Environmental Medicine, Department of Sports Medicine and Exercise Physiology, Goethe University Frankfurt, Ginnheimer Landstraße 39, 40487, Frankfurt, Germany.
| | | | - Max Wießmeier
- grid.7839.50000 0004 1936 9721Institute of Occupational, Social and Environmental Medicine, Department of Sports Medicine and Exercise Physiology, Goethe University Frankfurt, Ginnheimer Landstraße 39, 40487 Frankfurt, Germany
| | | | - Wolf Petersen
- Klinik für Orthopädie und Unfallchirurgie, Berlin, Germany
| | | | | | - Christian Schoepp
- grid.491667.b0000 0004 0558 376XBerufsgenossenschaftliche Unfallklinik Duisburg, Duisburg, Germany
| | | | - Andreas Fischer
- grid.5252.00000 0004 1936 973XDepartment of Orthopedic Surgery, Physical Medicine and Rehabilitation, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Andrea Achtnich
- grid.15474.330000 0004 0477 2438Department for Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Munich, Germany
| | - Raymond Best
- Department of Orthopaedic and Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
| | - Lucia Pinggera
- Department of Orthopaedic and Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
| | - Matthias Krause
- grid.13648.380000 0001 2180 3484Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Guenther
- grid.412581.b0000 0000 9024 6397Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Witten, Germany
| | - Maren Janko
- grid.7839.50000 0004 1936 9721Department of Trauma, Hand, and Reconstructive Surgery, Goethe-University Frankfurt, Frankfurt, Germany
| | - Christoph Kittl
- grid.16149.3b0000 0004 0551 4246Universitätsklinikum Münster, Munster, Germany
| | - Turgay Efe
- Orthopaedicum Lich Giessen, Lich, Germany
| | | | - Lutz Vogt
- grid.7839.50000 0004 1936 9721Department of Sport Sciences, Goethe University Frankfurt, Frankfurt, Germany
| | - Michael Behringer
- grid.7839.50000 0004 1936 9721Department of Sport Sciences, Goethe University Frankfurt, Frankfurt, Germany
| | - Thomas Stein
- SPORTHOLOGICUM Frankfurt - Center for Sport and Joint Injuries, Frankfurt, Germany ,grid.7839.50000 0004 1936 9721Department of Sport Sciences, Goethe University Frankfurt, Frankfurt, Germany
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Petersen W, Häner M, Guenther D, Lutz P, Imhoff A, Herbort M, Stein T, Schoepp C, Akoto R, Höher J, Scheffler S, Stöhr A, Stoffels T, Mehl J, Jung T, Eberle C, Vernacchia C, Ellermann A, Krause M, Mengis N, Müller PE, Best R, Achtnich A. Management after acute injury of the anterior cruciate ligament (ACL), part 2: management of the ACL-injured patient. Knee Surg Sports Traumatol Arthrosc 2022; 31:1675-1689. [PMID: 36471029 DOI: 10.1007/s00167-022-07260-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process. METHODS For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus. CONCLUSIONS This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Wolf Petersen
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Caspar-Theyß-Straße 27-31, 14193, Berlin-GrunewaldBerlin, Germany
| | - Martin Häner
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Caspar-Theyß-Straße 27-31, 14193, Berlin-GrunewaldBerlin, Germany.
| | - Daniel Guenther
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine Cologne Merheim Medical Center (Witten/Herdecke University), Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Patricia Lutz
- Department of Orthopaedics and Trauma Surgery, State Hospital Feldkirch, Carinagasse 41, 6800, Feldkirch, Austria
| | - Andreas Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Mirco Herbort
- OCM Clinic Munich, Steinerstrasse 6, 81369, Munich, Germany
| | - Thomas Stein
- SPORTHOLOGICUM® Frankfurt Am Main, Siesmayerstraße 44, 60323, Frankfurt Am Main, Germany
- Department of Sports Medicine, Goethe University Frankfurt, Ginnheimer Landstraße 39, 60487, Frankfurt Am Main, Germany
| | - Christian Schoepp
- Department of Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum, Duisburg gGmbH, Großenbaumer Allee 250, 47249, Duisburg, Germany
| | - Ralph Akoto
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - Jürgen Höher
- SPORTSCLINIC COLOGNE, Ostmerheiemer Str. 200, 51109, Cologne, Germany
| | - Sven Scheffler
- Sporthopaedicum Berlin, Bismarckstrasse 45-47, 10627, Berlin, Germany
| | - Amelie Stöhr
- OCM Clinic Munich, Steinerstrasse 6, 81369, Munich, Germany
| | | | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Christian Eberle
- ARCUS Sports Clinic, Rastatter Str. 17-19, 75179, Pforzheim, Germany
| | - Cara Vernacchia
- Department of Physical Medicine and Rehabilitation, Shirley Ryan Ability Lab, Chicago, IL, USA
- McGaw/Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andree Ellermann
- ARCUS Sports Clinic, Rastatter Str. 17-19, 75179, Pforzheim, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Natalie Mengis
- ARCUS Sports Clinic, Rastatter Str. 17-19, 75179, Pforzheim, Germany
- KSA Aarau/Spital Zofingen, Mühlethalstrasse 27, 4800, Zofingen, Schweiz
| | - Peter E Müller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart, Taubenheimstraße 8, 70372, Stuttgart, Germany
- Department of Sports Medicine and Orthopaedics, University of Tuebingen, Hoppe Seyler Strasse 5, 72074, Tuebingen, Germany
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany
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10
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Beck P, Reinecke F, Polan C, Meyer HL, Schoepp C, Burggraf M, Dudda M, Mester B. [Rupture of the pectoralis major muscle in amateur athletes: a rare injury or often overlooked?]. Sportverletz Sportschaden 2022; 36:155-159. [PMID: 35413736 DOI: 10.1055/a-1754-4524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION A rupture of the pectoralis major muscle is a rare injury pattern overall, but it is frequently described in athletes, particularly in weightlifting. The risk of sustaining this type of injury is present especially during the eccentric phase of muscle loading. An association between such injuries and the abuse of anabolic steroids is described in the literature, but there is no coherent evidence to support this. We report the case of a young patient with a normal habitus who suffered a humeral rupture of the pectoralis major muscle during recreational sports. There was no history of excessive weight training or use of anabolic steroids. CASE HISTORY This 33-year-old patient reported a sudden onset of left pectoral pain during training on the chest fly machine as well as a whip-like popping sound, followed by an immediate painful restriction of movement in the left arm. A clinical examination revealed a mild haematoma located on the left medial upper arm with localised tenderness and a discrete asymmetry of the contour of the pectoral muscles. Due to the typical medical history, we established the indication for surgical exploration although the clinical picture was rather discrete and only an incomplete rupture was seen in an MRI scan. Intraoperatively, we detected a complete rupture of the sternocostal part of the pectoralis major muscle with marked retraction and haematoma. Reinforcement and reinsertion were performed at the "footprint" using titanium anchors (2 x 5.5mm Corkscrew FT, Arthrex, Florida). The patient was able to resume his sports activities at the pre-traumatic level four months after surgery. CONCLUSION A rupture of the insertion of the pectoralis major muscle must also be considered in amateur athletes with a typical history. The characteristic clinical symptoms described in the literature mostly refer to competitive athletes and bodybuilders, but these injuries can also be diagnosed in amateur athletes with lower muscle mass by subtle clinical examination. Nevertheless, there is a considerable risk of underestimating the extent of the injury. In case of doubt, surgical exploration should be performed promptly in amateur athletes. Surgical refixation of the humeral rupture of the pectoralis major muscle is the gold standard and should not be reserved to high-performance athletes.
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Affiliation(s)
- Paula Beck
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, GERMANY
| | - Felix Reinecke
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, GERMANY
| | - Christina Polan
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, GERMANY
| | - Heinz-Lothar Meyer
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, GERMANY
| | - Christian Schoepp
- Klinik für Arthroskopische Chirurgie, Sporttraumatologie und Sportmedizin, BG Klinikum Duisburg, Duisburg, GERMANY
| | - Manuel Burggraf
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, GERMANY
| | - Marcel Dudda
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, GERMANY
| | - Bastian Mester
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, GERMANY
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11
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Guenther D, Pfeiffer T, Petersen W, Imhoff A, Herbort M, Achtnich A, Stein T, Kittl C, Schoepp C, Akoto R, Höher J, Scheffler S, Stöhr A, Stoffels T, Mehl J, Jung T, Ellermann A, Eberle C, Vernacchia C, Lutz P, Krause M, Mengis N, Müller PE, Patt T, Best R. Treatment of Combined Injuries to the ACL and the MCL Complex: A Consensus Statement of the Ligament Injury Committee of the German Knee Society (DKG). Orthop J Sports Med 2021; 9:23259671211050929. [PMID: 34888389 PMCID: PMC8649102 DOI: 10.1177/23259671211050929] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 01/13/2023] Open
Abstract
Background: Different indications and treatment options for combined injuries to the anterior cruciate ligament (ACL) and medial collateral ligament complex (MCL) are not clearly defined. Purpose: To perform a modified Delphi process with the Committee for Ligament Injuries of the German Knee Society (DKG) in order to structure and optimize the process of treating a combined injury to the ACL and MCL. Study Design: Consensus statement. Methods: Scientific questions and answers were created based on a comprehensive literature review using the central registers for controlled studies of Medline, Scopus, and Cochrane including the terms medial collateral ligament, anterior cruciate ligament, MCL, ACL, and outcome used in various combinations. The obtained statements passed 3 cycles of a modified Delphi process during which each was readjusted and rated according to the available evidence (grades A-E) by the members of the DKG Ligament Injuries Committee and its registered guests. Results: The majority of answers, including several questions with >1 graded answer, were evaluated as grade E (n = 16) or C (n = 10), indicating that a low level of scientific evidence was available for most of the answers. Only 5 answers were graded better than C: 3 answers with a grade of A and 2 answers with a grade of B. Only 1 answer was evaluated as grade D. An agreement of >80% (range, 83%-100%) among committee members was achieved for all statements. Conclusion: The results of this modified Delphi process offer a guideline for standardized patient care in cases of combined injuries to the ACL and MCL.
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Affiliation(s)
- Daniel Guenther
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Thomas Pfeiffer
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Wolf Petersen
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Andreas Imhoff
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Mirco Herbort
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Andrea Achtnich
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Thomas Stein
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Christoph Kittl
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Christian Schoepp
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Ralph Akoto
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Jürgen Höher
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Sven Scheffler
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Amelie Stöhr
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Thomas Stoffels
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Julian Mehl
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Tobias Jung
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Andree Ellermann
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Christian Eberle
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Cara Vernacchia
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Patricia Lutz
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Matthias Krause
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Natalie Mengis
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Peter E Müller
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Thomas Patt
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Raymond Best
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
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12
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Mester B, Guder W, Streitbürger A, Schoepp C, Nottrott M, Podleska L, Dudda M, Hardes J. Return to Sports and Activity in Tumor Orthopaedics. Z Orthop Unfall 2021. [PMID: 34879419 DOI: 10.1055/a-1676-5266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION As survival rates associated with the multimodal treatment of malignant bone cancer (osteosarcoma and Ewing's sarcoma) are satisfactory, health-related quality of life and the return to activity and sports by the affected patients have attracted increasing attention in recent years. Nowadays, limbs can be salvaged for most patients using modular endoprostheses. Such patients are typically adolescents and young adults who have high activity levels and thereby high demands for multimodal cancer treatment. This study aimed to evaluate the activity levels and sporting proficiencies that can be attained after modular endoprosthetic treatment of bone sarcomas as well as the extent to which physiotherapeutic and sports interventions influence functional outcome and activity levels. METHODS This non-systematic review of the literature focused on the return to activity and sports after modular endoprosthetic treatment of lower extremities bone sarcomas in adolescents and young adults. The electronic database PubMed was screened for relevant publications on this issue. A treatment algorithm for return to activity and sports in tumor orthopaedics is proposed. RESULTS AND DISCUSSION The objective activity level (gait cycles per day and gait intensities) in patients treated for bone sarcomas is reduced in short- and long-term follow-ups compared with healthy controls and patients with other cancers (leukaemia). Although a negative impact is observed in terms of motor performance, it shows improvement over time. Functional assessment at 12 postoperative months is sensible as neoadjuvant chemotherapy is completed by then. In long-term follow-up, patients with bone sarcomas can achieve high sports activity levels, i.e., type of sport, frequency/week and UCLA score, after modular endoprosthetic reconstruction. The maximum level is attained at 5 years postoperatively. Nevertheless, there is a shift from high- and intermediate- to low-impact sports. Only 20% of the patients participate in school sports regularly without limitations. The localisation of bone sarcoma, but not the rate of postoperative complications, influences the postoperative activity level. Individualised sports-related interventions during and after multimodal treatment can improve the short-term activity levels; moreover, "serious games" can improve motor performance and postural control. There is no evidence that intense activity levels leads to early loosening of the endoprosthesis. There is insufficient valid data on activity and sports after modular endoprosthetic treatment of bone sarcomas of the upper extremities. CONCLUSION High preoperative activity levels of young patients with bone sarcomas must be considered in tumour orthopaedics. Limitations on sports activities have a significant negative impact on the quality of life and mental health of such patients. Therefore, tumour orthopaedic treatment has to focus on preserving an improvement in these factors. The overall existing evidence concerning this issue is weak. Additional studies to evaluate the ability to return to specific sports activities are desirable, as well as prospective interventional studies.
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Affiliation(s)
- Bastian Mester
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Wiebke Guder
- Klinik für Tumororthopädie und Sarkomchirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Arne Streitbürger
- Klinik für Tumororthopädie und Sarkomchirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Christian Schoepp
- Klinik für Arthroskopische Chirurgie, Sporttraumatologie und Sportmedizin, BG Klinikum Duisburg, Universität Duisburg-Essen, Duisburg, Deutschland
| | - Markus Nottrott
- Klinik für Tumororthopädie und Sarkomchirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Lars Podleska
- Klinik für Tumororthopädie und Sarkomchirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Marcel Dudda
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Universität Duisburg-Essen, Duisburg, Deutschland.,Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Jendrik Hardes
- Klinik für Tumororthopädie und Sarkomchirurgie, Universitätsklinikum Essen, Essen, Deutschland
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Raeder C, Tennler J, Praetorius A, Ohmann T, Schoepp C. Delayed functional therapy after acute lateral ankle sprain increases subjective ankle instability - the later, the worse: a retrospective analysis. BMC Sports Sci Med Rehabil 2021; 13:86. [PMID: 34362431 PMCID: PMC8344223 DOI: 10.1186/s13102-021-00308-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/12/2021] [Indexed: 12/26/2022]
Abstract
Background The lateral ankle sprain (LAS) is one of the most common injuries in everyday and sports activities. Approximately 20–40 % of patients with LAS develop a chronic ankle instability (CAI). The underlying mechanisms for CAI have not yet been clearly clarified. An inadequate rehabilitation after LAS can be speculated, since the LAS is often handled as a minor injury demanding less treatment. Therefore, the aims of this retrospective study were to determine the CAI rate depending on age and sex and to identify possible determinants for developing CAI. Methods Between 2015 and 2018 we applied the diagnostic code “sprain of ankle” (ICD S93.4) to identify relevant cases from the database of the BG Klinikum Duisburg, Germany. Patients received a questionnaire containing the Tegner-Score, the Cumberland Ankle Instability Tool (CAIT) and the Foot and Ankle Disability Index. Additionally, there were questions about the modality and beginning of therapy following LAS and the number of recurrent sprains. There was a total of 647 completed datasets. These were divided into a CAI and non-CAI group according to a CAIT cut-off-score with CAI ≤ 24 and non-CAI > 24 points, representing one out of three criteria for having CAI based on international consensus. Results The overall CAI rate was 17.3 %. We identified a higher CAI rate in females and within the age segment of 41 to 55 years. A later start of therapy (> 4 weeks) after acute LAS significantly increases ankle instability in CAIT (p < .05). There was a significantly higher CAIT score in patients having no recurrent sprain compared to patients having 1–3 recurrent sprains or 4–5 recurrent sprains (p < .001). Conclusions Females over 41 years show a higher CAI rate which implies to perform specific prevention programs improving ankle function following acute LAS. A delayed start of therapy seems to be an important determinant associated with the development of CAI. Another contributing factor may be a frequent number of recurrent sprains that are also linked to greater levels of subjective ankle instability. Therefore, we would recommend an early start of functional therapy after acute LAS in the future to minimize the development of CAI.
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Affiliation(s)
- Christian Raeder
- Clinic for Arthroscopic Surgery, Sports Traumatology & Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany.
| | - Janina Tennler
- Research Department, BG Klinikum Duisburg, Duisburg, Germany
| | - Arthur Praetorius
- Clinic for Arthroscopic Surgery, Sports Traumatology & Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
| | - Tobias Ohmann
- Research Department, BG Klinikum Duisburg, Duisburg, Germany
| | - Christian Schoepp
- Clinic for Arthroscopic Surgery, Sports Traumatology & Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
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Gensior TJ, Mester B, Ullerich F, Colcuc S, Schoepp C. Primäre Spongiosaplastik und AMIC® bei Tibiakopffraktur. Arthroskopie 2019. [DOI: 10.1007/s00142-019-0294-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Henkelmann R, Frosch KH, Glaab R, Lill H, Schoepp C, Seybold D, Josten C, Hepp P. Infection following fractures of the proximal tibia - a systematic review of incidence and outcome. BMC Musculoskelet Disord 2017; 18:481. [PMID: 29162084 PMCID: PMC5699108 DOI: 10.1186/s12891-017-1847-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 11/14/2017] [Indexed: 11/23/2022] Open
Abstract
Background To systematically review all available studies of operatively treated proximal tibia fractures and to report the incidence of superficial or deep infection and subsequent outcomes. Methods A systematic review of the literature in Medline, Cochrane, Embase and GoogleScholar was conducted to identify studies with cohorts of patients with infection after surgical treatment of proximal tibia fractures. Studies were included according to predefined inclusion and exclusion criteria. The studies were analysed for methodological deficiencies and quality of outcome reporting based on the Level of Evidence (LOE) and Coleman Methodology Scoring (CMS.) Results In total 32 studies were included. There was heterogeneity between the studies, in terms of subject of the studies, outcome criteria, fracture type and classification, surgical techniques and length of follow-up. Therefore, no meta-analysis could be performed. The average CMS was 54.2 (range 36–75). The included studies were 25 case series (LOE IV), 6 were prospective cohort studies (LOE III) and one was a prospective randomized trial (LOE I). 203 (12.3%, range: 2.6–45.0%) infections occurred in the overall population (n = 2063). Those were divided into 129 deep infections and 74 superficial infections. Revision due to infection was reported in 29 studies, microbiological results in 6, respectively. 72 (55,8%) of 129 cases reporting outcome after deep infection had an unsatisfactory outcome with substantial limitations of the affected joint and leg. Conclusions Postoperative infections are a challenge, sometimes requiring several revisions and often with a worse outcome. Further studies with structured study protocols should be performed for a better understanding of risk factors to improve treatment outcomes.
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Affiliation(s)
- Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Reconstructive Surgery with Divion of Knee and Shoulder Surgery, Sports Traumatology, Asklepios Clinic St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany
| | - Richard Glaab
- Departmet of Traumatology, Cantonal Hospital Aarau, Tellstrasse 25, CH-5001, Aarau, Switzerland
| | - Helmut Lill
- Department of Trauma and Reconstructive Surgery, DIAKOVERE Friederikenstift gGmbH, Humboldtstr. 5, 30169, Hannover, Germany
| | - Christian Schoepp
- Departement of Orthopedic and Trauma Surgery, Berufsgenossenschaftliche Unfallklinik Duisburg, Großenbaumer Allee 250, 47249, Duisburg, Germany
| | - Dominik Seybold
- Department of General and Trauma Surgery, University Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Pierre Hepp
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
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Mester B, Ullerich F, Ohmann T, Glombitza M, Schoepp C. Ankylosis of the knee after septic arthritis following anterior cruciate ligament reconstruction in a 13-year-old male. Orthop Traumatol Surg Res 2017; 103:619-622. [PMID: 28342819 DOI: 10.1016/j.otsr.2017.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 02/02/2023]
Abstract
We present the case of an adolescent male developing an ankylosis of the knee after septic arthritis following anterior cruciate ligament reconstruction (ACLR). The patient was shifted to our institution with postoperative septic arthritis associated with a systemic septic condition. Before, repeated arthroscopic surgery had been conducted without any improvement. MRI showed a concomitant osteomyelitis. The infection (Gächter IV, Staphylococcus aureus) was controlled by an open surgical approach and graft removal. An increasing joint stiffness was documented. X-rays showed an ankylosis at 30° of flexion and early closure of growth plates. Functional knee scores showed significantly worse results. Early diagnosis and a stage-adapted treatment in septic arthritis following ACLR are mandatory. In advanced stages or concomitant osteomyelitis an open approach and graft removal may be appropriate. The antibiotic treatment should be adapted consistently.
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Affiliation(s)
- B Mester
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Germany.
| | - F Ullerich
- Klinik für Arthroskopische Chirurgie, Sporttraumatologie und Sportmedizin, BG Klinikum Duisburg, Germany
| | - T Ohmann
- Forschungsabteilung, BG Klinikum Duisburg, Germany
| | - M Glombitza
- Klinik für Orthopädie und Unfallchirurgie, BG Klinikum Duisburg, Germany
| | - C Schoepp
- Klinik für Arthroskopische Chirurgie, Sporttraumatologie und Sportmedizin, BG Klinikum Duisburg, Germany
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Henkelmann R, Krause JT, Frosch KH, Lill H, Schoepp C, Seybold D, Josten C, Hepp P. Outcome nach Infektion operativ versorgter Tibiakopffrakturen – ein systematischer Review und erste retrospektive Analyse. Zentralbl Chir 2016. [DOI: 10.1055/s-0036-1586340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Arthroscopic fracture management of the ankle and calcaneus requires a differentiated approach. The aim is to minimize surgical soft tissue damage and to visualize anatomical fracture reduction arthroscopically. Moreover, additional cartilage damage can be detected and treated. The arthroscopic approach is limited by deep impressions of the joint surface needing cancellous bone grafting, by multiple fracture lines on the articular side and by high-grade soft tissue damage. An alternative to the minimally invasive arthroscopic approach is open arthroscopic reduction in conventional osteosynthesis. This facilitates correct assessment of surgical reduction of complex calcaneal fractures, otherwise remaining non-anatomical reduction might not be fluoroscopically detected during surgery.
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Affiliation(s)
- C Schoepp
- Berufsgenossenschaftliche Unfallklinik Duisburg, Großenbaumer Allee 250, 47249 Duisburg.
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Fiedler VU, Schwarzmaier HJ, Eickmeyer F, Müller FP, Schoepp C, Verreet PR. Laser-induced interstitial thermotherapy of liver metastases in an interventional 0.5 Tesla MRI system: technique and first clinical experiences. J Magn Reson Imaging 2001; 13:729-37. [PMID: 11329194 DOI: 10.1002/jmri.1101] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Laser-induced interstitial thermotherapy (LITT) surveyed by magnetic resonance imaging (MRI) has been shown to be effective in various applications. The laser treatment of colorectal liver metastases usually requires a separate device (e.g., ultrasound or CT) to position the laser applicator. In this study, we used an interventional 0.5 T MRI system, allowing both the navigation to the target tissue and on-line thermometry. Laser irradiation was performed using a near-infrared laser source combined with a cooled laser light guide. We treated 20 patients exhibiting a total of 58 colorectal liver metastases. Clinically relevant complications did not occur. No residual tumor was observed after laser irradiation in all metastases with a diameter below 2 cm. Metastases with a mean diameter between 2 and 3 cm demonstrated total necrosis in 71%, while in larger tumors this proportion decreased to 46% (diameter, 3-4 cm) and 30% (diameter, >4 cm), respectively. We conclude that LITT, guided by the employed interventional MRI system, is feasible and safe. The results suggest a more aggressive treatment, especially for larger metastases. J. Magn. Reson. Imaging 2001;13:729-737.
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Affiliation(s)
- V U Fiedler
- Department of Diagnostic Radiology, Klinikum Krefeld, Lutherplatz 40, D-47805 Krefeld, Germany
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Abstract
Gastrointestinal stromal tumors (GIST) have been regarded as rare tumor manifestations of the mesenchymal tissue fraction of the intestinal building principle; however, this tumor is now established as an independent tumor entity owing to independent immunohistochemical and ultrastructural characteristics. In spite of increasing awareness of their biological behavior and their molecular-biological basis, evaluating the grade of many of these tumors remains open, not only on a preoperative but also on a postoperative basis. Thus, how radical the surgical procedure must be is not standardized, as it is in carcinoma surgery. The literature available today is not sufficient to make a valid analytical assumption possible because of small numbers of cases and the heterogeneity of clinical and pathological variables. Therefore, recommendations concerning oncological-surgical radicality have at this time an empirical character. Owing to the rarity of the tumor, this will probably not change in the near future. Adjuvant therapeutical treatment of relevant effectiveness does not exist. Therefore, the radicalness of the operation is organ-specific, tumor-specific and based on tumor-biological criteria.
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Affiliation(s)
- P R Verreet
- Klinik für Allgemein- und Viszeralchirurgie, Zentrum für Chirurgie, Klinikum Krefeld.
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