Purpose: Evaluation of the inter- and intra-observer reliability of a new developed knee laxity measurement device for tibiofemoral rotation.

Methods: 30 healthy subjects (15m, 15w, mean age of 24 years) were examined with the Rotameter knee laxitiy measurement device. The Beigthon score was reported to test the general laxitiy of the subjects.

After fixation of the device on the lower extremity and positioning of the patient in the starting position the device was first externally and then internally rotated at an applied torque of 5,10 and 15 Nm. To decrease the measurement error the procedure was repeated 5 times. Afterwards 5 measurements were performed by a second examiner in the same way to measure the inter-observer reliability. All 30 patients were measured again after a mean of 31 ± 43 days by the same examiners to test the intra-observer reliability. Statistical analysis was performed using the intra class correlation coefficient (ICC). Pearson correlation coefficient were used to compare the measurements of the left and the right knee.

Results: The Beigthon Score showed a mean of 0.8 ± 1.1 (0–4). At an applied torque of 5 Nm the ICC for the intra-observer reliability of was 0.81 for the external rotation and 0.67 for the internal rotation, the ICC for the inter-observer reliability was 0.94 for the external and 0.94 for the internal rotation. At 10 Nm of rotation torque an ICC for the intra-observer reliability of 0.79 was reached for internal and 0.88 for external rotation, the ICC for the inter-observer reliability was 0.97 for internal and 0.95 for external rotation. At the highest applied torque of 15 Nm an ICC for the intra-observer reliability of 0.93 was observed for the external rotation and 0.83 was found for internal rotation. For the inter-tester reliability the ICC was 0.95 for external and 0.98 for internal rotation.

The comparison of the measurements of the left and the right knee showed high Pearson correlation (.90) at all applied torques.

Conclusion: The Rotameter testing device for the measurement of tibiofemoral rotation showed a high inter-observer and intra-observer reliability. It is easy to perform and might be used in a wide field to examine the rotational stability of the knee.

Purpose: The objective of this investigation was to evaluate the precision of tibial tunnel drilling for anatomic anchoring of meniscus transplants at the tibial insertion area, using previously obtained percentage references.

Methods: In 20 cadaveric tibial heads, anterior and posterior horn insertions of both the lateral and the medial meniscus were dissected and their circumferences outlined. Standardized photographs of the tibial plateau were obtained. Applying previously obtained percentage values for radiographic determination of the meniscus insertion midpoints, tibial tunnels were drilled with the use of a standard ACL-guide. The positioning of the drilling guide was performed by solely using the midpoints as determined on standard ap and lateral radiographs; during the procedure, no position correction related to the anatomic insertions was made. After tibial tunnel drilling, a second set of standardized photographs of the tibial plateau was obtained. Adobe Photo Shop permitted the superposition of pre- and postoperative images. Coincidence between the anatomic insertion areas and the footprint of the tibial tunnel exit was determined, as well as the distance between the borders of the insertion areas and the tunnel footprint.

Results: For the lateral meniscus, the mean coincidence of insertion area and tunnel footprint was 60.5 ± 34.6 % for the anterior horn insertion and 62.4 ± 32.0 % for the posterior horn insertion. The mean distance between the borders of insertion area and tunnel footprint was 1.7 ± 1.5 mm for the anterior horn insertion and 2.3 ± 1.7 mm for the posterior horn insertion.

For the medial meniscus, the mean coincidence of insertion area and tunnel footprint was 88.4 ± 15.5 % for the anterior horn insertion and 60.3 ± 31.6 % for the posterior horn insertion. The mean distance between the borders of insertion area and tunnel footprint was 0.8 ± 0.8 mm for the anterior horn insertion and 2.1 ± 1.4 mm for the posterior horn insertion.

Conclusions: The use of percentage references for tibial meniscus insertion midpoint determination in combination with a radiographic positioned standard ACL-guide permits a precise drilling of tibial tunnels at the anatomic location of the meniscus insertions.

Clinical relevance: Enhancement of the surgical technique for bone plug fixation of lateral and medial meniscus transplants.

Background: Comparison of intra-articular corticoid injections and oral corticosteroids in the treatment of adhesive capsulitis of the shoulder

Methods: In a prospective randomized evaluation two different treatment regimen were compared. 40 patients with idiopathic adhesive capsulitis of the shoulder were treated either with an oral (20) corticoid treatment regimen for 4 weeks or intra-articular (20) injection series of corticosteroids (3 injections- 4, 8, 12 weeks).Patient groups were comparable in sex, age and affected side. Follow-up periods were after 4,8,12 weeks, 6 and 12 months. For the clinical evaluation the Constant and Murley Score, the Simple Shoulder Test and visual analog scales for pain, function and satisfaction were used.

Results: In the patients group treated with oral glucocorticoids significant improvements were found for the Constant and Murley Score (p< .0001), the Simple Shoulder Test (p=.035) and range of motion for flexion (p< .0001), abduction (p< .0001), external (p=.001) and internal rotation (p=.028) already at 4 weeks follow-up. The visual analog scales for pain, function and patient satisfaction also improved significantly after 4 weeks of treatment (p< .0001).)

The patient group treated with an intra-articular glucocorticoid injection series also showed significant improvements for the Constant and Murley Score (p< .0001), the Simple Shoulder Test (p< .0001) and the visual analog scales for pain, function and patient satisfaction (p< .0001) after 4 weeks and also at any other follow up. Significant improvements were also seen in abduction (p< .0001), flexion (p< .0001) and external rotation (p=.001) and internal rotation (p=.035) after 4 weeks of treatment. These results were confirmed at any other follow up.

Comparison of the two treatment regimen showed superior short term results for the intra-articular treatment regimen in range of motion, Constant Score and Simple Shoulder Test and patient satisfaction (p< .05). No significant differences were found in the visual analog scales for pain and function (p> .05).

Conclusion: The use of cortisone in the treatment of idiopathic adhesive capsulitis of the shoulder leads to fast pain relief and improves range of motion. Intra-articular injections of glucocorticoids showed superior short term results in objective shoulder scores, range of motion and patient satisfaction compared with a short course of oral corticosteroids.

Implantation of antibiotic-loaded beads is accepted as an efficient option for local antibiotic therapy in orthopedic-related infections. However, recent reports have emphasized the bacteria growth persistence on antibiotic-impregnated bone cement. Hence, the aim of this study was to elaborate if bacterial adherence and growth could be determined on explanted gentamicin- and gentamicin-vancomycin-loaded beads after infection eradication. 18 chains of antibiotic-loaded beads (11 gentamicin-, 7 gentamicin-vancomycin-loaded) were examined. Indications for primary beads implantation included postoperative infections after total hip or knee arthroplasty, rotator cuff reconstruction, chronic foot osteomyelitis, anterior cruciate ligament reconstruction and dorsal spondylodesis. Among the isolated organisms, Staphylococcus epidermidis, Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent ones. In 4 cases (3 × S. epidermidis, 1 × MRSA) bacteria growth persistence could be determined on the beads. S. epidermidis-strains persisted only on gentamicin-loaded beads, MRSA could grow on gentamicin-vancomycin-impregnated cement. In one case, the emergence of a gentamicin-resistant S. epidermidis-strain could be observed despite preoperative susceptibility. Bacteria growth persistence on bone cement is a hazardous problem in the orthopedic surgery and should therefore be born in mind. Adherence to cement can lead to emergence of bacteria resistance despite preoperative antibiotic susceptibility and might result in clinical recurrence of infection.

Introduction: The purpose of our investigation was to determine if tibial lateral meniscus insertions (anterior and posterior horn) can precisely and reproducibly be determined on preoperative radiographs. Bony landmarks and their topographic relations to the meniscus insertions were described, measured and statistically evaluated. We concentrated on the lateral meniscus because there are many reasons to restrict the indications for meniscus replacement on the lateral compartment.

Methods: We prepared the lateral meniscus insertions in 22 tibial plateaus from 11 body donors. Insertion site outline was performed on anterior and posterior horns with radio opaque 1.6 mm steal balls. Anteroposterior and lateral radiographs were performed. On these radiographs, different landmarks of the tibial head were defined and their distances measured (width, depth, distance from lateral tibia border to meniscus midpoint, distance from lateral tibia border to lateral tibial spine). These measures were statistically evaluated and percent values for meniscus insertion midpoint position were determined.

Results: On anteroposterior radiographs, from lateral to medial, the anterior meniscus midpoint was located on 45.1 % ± 1.3 % of the tibial width, the posterior meniscus midpoint on 49.8 % ± 1.9 % of the tibial width. On lateral radiographs, from anterior to posterior, the anterior meniscus midpoint was located on 41.9 % ± 3.2 % of the tibial depth, the posterior meniscus midpoint on 72.1 % ± 2.3 % of the tibial depth. With linear regression analysis, we could show that the lateral meniscus insertions have constant relations, as well to the dimensions of the tibia plateau as to the lateral tibial spine.

Conclusions: We think that it is possible to determine precisely and reproducibly on preoperative anteroposterior and lateral radiographs the insertions of the lateral meniscus. Our results and the method to determine preoperatively meniscus insertions might bring decisive advantages considering the optimal fixation of meniscus transplants, enhancing biomechanical conditions and possibly improving postoperative results.

Aims: The purpose of this study was to evaluate primary stability and the time of bony þxation of two different designed cementless titanium hip stems. Therefore we designed a prospective clinical study with high precision RSA and close follow up periods (3, 6,12, 24, 52, 104 weeks). Methods: One stem was a Ç straight stem È (BICONTACT, Aesculap AG, Germany) with a rough pure Titanium surface in the upper part for proximal þxation. The second stem (Image, Smith& Nephew, Germany) was anatomically shaped with additional HA coating. 34 IMAGE stems and 20 BICONTACT stems with RSA markers were implanted. Mean age in both groups was 64 years. In September 2002, 28 patients (14 X BICONTACT and 16 X IMAGE) were followed for more than 1 year and 12 patients (6 X BICONTACT and 6 X IMAGE) for more than 2 years. Results: Subsidence was predominantly observed between the postoperative control and the 6 weeks follow up. (IMAGE 0.83mm, BICONTACT 0,60mm) and decreased up to 12 weeks (IMAGE 0.05mm, BICONTACT 0,29mm). After 12 weeks both stems were stabilized (12–24 weeks: IMAGE 0.05mm, BICONTACT 0.06mm; 6 months -1 year: IMAGE 0.05mm, BICONTACT 0.04mm. Between 1 and 2 years subsidence for the IMAGE stem was 0.05mm compared to 0.16mm in the Bicontact group. Overall subsidence of the IMAGE stem during the þrst year was 0.96mm compared to 0.97mm for the BICONTACT stem. Conclusions: Titanium cementless hip stems with a rough proximal titanium surface or HA coating showed a sufþcient primary and mid-term stability. Bony þxation is achieved between 6 and 12 weeks. No statistical differences were found between both stems.

Sutures are the strongest and the only time proven technique for meniscal repair. Sutures are safe and without surprises as long as the peroneal and the saphenus nerves are protected and avoided. Sutures can be placed via arthrotomy or under arthroscopic view. In pure suture techniques a sling holds the meniscus parts together or refixes the meniscus to the capsule. The orientation of the sling can be vertical, horizontal or oblique, but should always either catch the circumferential fibre bundles of the meniscal tissue or part of the densely woven meniscal surface. Suture related techniques make use of a thread but do not strive to form a sling. The earliest of these was the knot-end technique, the latest one is the Fastfix? repair. Either absorbable or non-absorbable material has been recommended but most would favour non-absorbable threads of 0 or 1–0 USP sizes. Depending on the course of the needle inside-out, outside-in and all-inside techniques have been described. For repair of intrasubstance tears the sutures have to be supplemented by measures to enhance healing as trephination of the meniscal periphery or addition of a fibrin clot to the repair side.

There are regions of the menisci that are close to impossible to reach for the suture cannulas. For these it seems better to do a non-suture reconstruction with some of the innovative devices compared to leaving them alone or do meniscectomy instead of repair. Hybrid meniscal rapair, combining the advantages of sutures and new repair devices are in frequent use.

Aims: The purpose was to evaluate the biomechanical properties of Hamstring graft fixation methods with ability for circumferential graft ingrowth in a standardized experiment with high precision Radiostereometric Analysis (RSA). Methods: We used 30 porcine specimens for the study. A fourstranded graft was sutured with a baseball stitch. Ten trials were performed in each group. The sutured end of the graft was fixed with a Washer-Lock (WL) or two resorbable Cross-Pins (CP). In the Suture-Disc (SD) group 8 polyester sutures (Ethibond 5USP) were knotted over a titanium button. The tibial bone and the tendon-graft were marked with tantalum beads. The grafts were loaded axially under RSA control increasing the force in steps of 50N to load of failure. Micromotion between tendon graft and tibial bone was measured with RSA. Results: Load at failure was significantly higher for the WL and CP fixation (722±173N; 647±129N) compared to SD fixation (445±37N). Stiffness of fixation was significantly higher for WL and CP fixation 492N/mm; 416N/mm) compared to SD fixation 111N/mm). Graft displacement started at low loads for SD fixation (47N) compared to WL and CP (344N; 250N). Graft motion at 200N load was significantly higher in the SD group (1.85mm) than for the WL (0.33mm) and CP (0.3mm) fixation. Bungee cord effect at 200N for the SD was measured 1.32mm, for the CP 0.50mm and for the WL 0.22mm in average. Conclusions: Direct fixation of a quadrupled tendon graft with WL or CP is preferable to SD fixation. Low linear stiffness of SD fixation with linkage suture material allows for a high amount of elastic deformation.

The Fulkerson osteotomy has proved to be a reliable treatment for subluxation of the patella due to malalignment. Aggressive rehabilitation in the early postoperative period is unwise since the proximal tibia is weakened by the oblique osteotomy. Early weight-bearing and unrestricted activity have caused fractures in a few patients. Even late in the postoperative period the osteotomy may adversely influence the biomechanical properties of the proximal tibia.

We describe two athletes who sustained a fracture of the proximal tibia, during recreational activities, six months after a Fulkerson osteotomy. Both had been bearing full weight for about ten weeks without complaint. Bony healing of the osteotomy had been demonstrated on plain radiographs at ten and at 12 weeks. After a Fulkerson osteotomy, jogging and activities which impose considerable impact force should be discouraged for at least nine to 12 months.

Our aim was to analyse the effect of avascularity on the morphology and mechanical properties (tensile strength, viscoelasticity) of human bone-patellar-tendon-bone (BPTB) grafts in vitro. These were harvested at postmortem and stored submerged in denaturated human plasma at a constant pH, pO₂, pCO₂, temperature and humidity under sterile conditions. Mechanical testing was performed two and four weeks after removal of the graft. The mean ultimate strength was 1085.7 ± 255.8 N (control), 1009.0 ± 314.9 N (two weeks cultured) and 1076.8 ± 414.8 N (four weeks cultured). There was no significant difference in linear stiffness or deformation to failure between the groups. There was a difference in viscoelasticity between the control group and the avascular grafts and the latter had significant lower peak load-to-load ratios after 15 minutes compared with the control group. After two and four weeks the graft contained viable fibroblasts. There was regular cellularity in the superficial layers and decreased cellularity in the midportion. The structure of the collagen including the crimp pattern appeared to be normal in polarised light.

We conclude that avascularity does not significantly affect ultimate failure loads or stiffness of BPTB grafts. Slight changes in viscoelasticity were induced, but the significance of the increased stress relaxation is not fully understood.

In 20 skeletally mature female merino sheep, divided into four groups, we performed total medial meniscectomy, removal of the middle third of the patellar tendon, and tenotomy of the calcaneal tendon of the right hind leg. Group I (control) had no additional procedures. In the other three groups the medial meniscus was replaced by the middle third of the patellar tendon from the ipsilateral knee. The animals were killed at three (group II), six (group III), or 12 months (group IV) and the tendon-meniscus examined macroscopically, by light and scanning electron microscopy, and biomechanically. Remodelling of the tissue had taken place by 12 months but the failure stress and tensile modulus for the tendon-meniscus were lower than for the normal meniscus. Our evidence suggests that, in sheep, replacement of a meniscus by a tendon autograft may decrease the severity of the degenerative changes that occur after meniscectomy.