Analyse aktueller Nachbehandlungskonzepte nach operativer Versorgung des Kniegelenkes

Einleitung Das Kniegelenk ist das am häufigsten operativ versorgte Gelenk. Der Nachbehandlung derartiger Eingriffe kommt eine besondere Bedeutung zu, da sie den operativen Erfolg sichert und die schrittweise Rückführung zu voller Funktionalität gewährleistet. Methodik Um den aktuellen Stand der Rehabilitation nach operativer Versorgung des Kniegelenkes abzubilden, wurden Nachbehandlungsrichtlinien von 120 orthopädisch-unfallchirurgischen Institutionen untersucht. Die Module Gewichtsbelastung, Bewegungsausmaß, Orthesenversorgung, Bewegungsschienen-Therapie sowie Reha- und Sportartspezifisches Training wurden innerhalb der Hauptgruppen Knorpel-, Kreuzband-, Meniskus-, Patellachirurgie und Endoprothetik einander gegenübergestellt und mit den Empfehlungen der aktuellen Literatur verglichen. Ergebnisse Trotz Etablierung knorpelchirurgischer Operationstechniken zeigt sich eine hohe Variabilität in der Nachbehandlung. Der größte Konsens besteht in Hinblick auf die Empfehlungen zur Abstufung der Gewichtsbelastung. Nach operativer Versorgung von Kreuzbandverletzungen sind für die weitere Nachbehandlung v. a. die Begleitverletzungen wie Innenband- oder Meniskusverletzungen von Bedeutung, die einer prolongierten und speziellen Nachbehandlung bedürfen. Standardisierte Nachbehandlungsprotokolle sind nach derartigen Eingriffen jedoch nicht etabliert. Die Rehabilitation nach Meniskusrefixation variiert ebenso stark. Es sind v. a. bei der Gewichtsbelastung und dem Bewegungsausmaß Unterschiede sowohl innerhalb der untersuchten Richtlinien als auch im Vergleich mit der aktuellen Literatur festzustellen. Zur Nachbehandlung nach MPFL-Rekonstruktion kann gezeigt werden, dass sie ebenfalls einer hohen Variabilität unterliegt. Ein Konsens ist in keinem Modul der Nachbehandlung auszumachen. Demgegenüber ist ein standardisiertes Vorgehen nach konservativer Therapie des instabilen Patellofemoralgelenkes etabliert. Nach endoprothetischen Eingriffen wird aktuell ein standardisiertes evidenzbasiertes Vorgehen empfohlen. Unterschiede in der Nachbehandlung von Totalendoprothese im Vergleich zu einer Hemi-Prothese ergibt die Untersuchung nicht. Fazit Insgesamt zeigt diese Studie, dass nach operativer Versorgung des Kniegelenkes nicht nach einem standardisierten Protokoll nachbehandelt wird. Jedoch gibt es bezüglich der Heterogenit�at der Empfehlungen große Unterschiede zwischen den Hauptgruppen der Kniechirurgie. Es sind für die Module der Rehabilitation, v. a. für Rehaspezifisches und Sportartspezifisches Training hinsichtlich der Art und des optimalen Zeitpunktes des Trainings, weitere Untersuchungen zur Etablierung einer standardisierten Rehabilitation nötig, um in Zukunft die bestmögliche, evidenzbasierte Nachbehandlung zu gewährleisten

Symptomatic Diastasis Rectus Abdominis in Children: Review of Current Management Options and Presentation of a Novel Minimally Invasive Epifascial Repair Technique

Several surgical techniques are available for an adult patient collective with diastasis recti. Only few research papers addresses the treatment options of diastasis of the rectus abdominis in children. In this case series, we present a new technique of epifascial repair as a novel possibility in successfully repairing defects of the anterior abdominal wall using minimally invasive surgery. In this case series, we present an epifascial repair technique for patients with a diastasis recti with a dehiscence cranial of the umbilicus. Four pediatric patients with symptomatic rectus diastasis were treated with this new surgical technique. All procedures were conducted successfully, and no recurrence was observed in the follow up. All patients showed clinical regression of the rectus diastasis without any postoperative abdominal wall protrusion and good improvement of the symptoms. Intraoperative intraperitoneal air loss, postoperative scar keloid, thermal lesions due to Ultracision and one seroma/hematoma after the removal of the drain were minor complications observed during the follow-up

Timing return-to-competition: a prospective registration of 45 different types of severe injuries in Germany’s highest football league

Introduction Many professional football players sustain at least one severe injury over the course of their career. Because detailed epidemiological data on different severe injuries in professional football have been missing so far, this study describes the frequency and return-to-competition (RTC) periods of different types of severe football injuries. Material and methods This epidemiological investigation is a prospective standardised injury analysis based on national media longitudinal registration. Injuries were classified according to the consensus statement by Fuller et al. (2006). The analysis includes injuries sustained by players of the first German football league during the seasons 2014–2015 to 2017–2018. Level of evidence: II. Results Overall, 660 severe injuries were registered during the four seasons (mean 165 per season; 9.2 per season per team; incidence in 1000 h: 0.77). The body region most frequently affected by severe injury was the knee (30.0%; 49.5 injuries per season/SD 13.2) followed by the thigh (26.4%; 43.5 injuries/SD 4.2) and the ankle (16.7%; 27.5 injuries/SD 5.0). The distribution of injuries over the course of a season showed a trend for ACL ruptures to mainly occur at the beginning of a season (45.8%), overuse syndromes such as achillodynia (40.9%) and irritation of the knee (44.4%) during the winter months and severe muscle and ankle injuries at the end of a season. ACL ruptures showed the longest RTC durations (median 222 days). Conclusion This study presents detailed epidemiological data on severe injuries in professional football. The body region most frequently affected by severe injuries was the knee. Several types of severe injuries showed a seasonal injury pattern. The appropriate timing of RTC after an injury is one of the most important and complex decisions to be made. This study provides information on the typical time loss due to specific severe football injuries, which may serve as a guideline

Standardized Rehabilitation or Individual Approach?—A Retrospective Analysis of Early Rehabilitation Protocols after Isolated Posterior Cruciate Ligament Reconstruction

(1) Background: Isolated posterior cruciate ligament (PCL) tears represent a severe type of injury. In hospitals, PCL reconstruction (PCL-R) is less frequently performed than other types of knee surgery. It is unclear whether there is consensus among surgeons on how to perform rehabilitation after PCL-R or if there are different, more individual approaches in daily routines. (2) Methods: Rehabilitation protocols and their main criteria (the progression of weight bearing and range of motion, the use of knee braces, rehabilitation training, and sports-specific training) were retrospectively analyzed after PCL-R. (3) Results: Only 33 of 120 (27.5%) analyzed institutes use rehabilitation protocols after PCL-R. The applied protocols showed vast differences between the individual rehabilitation criteria, especially with regard to the progression of weight bearing and the range of motion. The only standardized recommendations were the obligatory use of knee braces and the general restriction of weight bearing and range of motion immediately post-surgery. Therefore, because of the lack of a consensus about a standardized rehabilitation protocol after PCL-R, no recommendation can be made on one particular protocol. (4) Conclusion: There is no acknowledged standardized rehabilitation protocol after PCL-R. In clinical practice, recommendations are influenced by, i.a., surgeons’ opinions and experience. The lack of scientific evidence on a particular standardized rehabilitation protocol after PCL-R suggests that rehabilitation protocols need to be tailored to the individual patient

Playing Football as a Risk Factor for Lower Leg Malalignment?—Comparing Lower Leg Axis of Male Adolescent Football Players and Referees

The prevalence of varus knee malalignment among junior and adult football players (FP) has proven to be higher compared to other sports. No causal relationship has yet been found, as genu varum can be assumed to be an independent risk factor for the development of knee osteoarthritis. The purpose of this study is to compare knee alignment measurements and sport-specific data of adolescent football players and referees (REF). Knee alignment was detected by measuring the intercondylar/intermalleolar distance (ICD/IMD) as well as the Hip–Knee–Ankle angle (HKA) using a standardized digital frontal-plane photograph. Anthropometric and sports-related data (training/match exposure, seasons actively played, etc.) were collected by means of questionnaires (Clinical trial registration number: DRKS00020446). A total of 28 male FP and 29 male adolescent REF were included in the survey. The mean age was 17.4 ± 0.7 years. The two groups did not differ significantly in age, height, weight, BMI, and overall football/refereeing exposure per week (FP vs. REF: 274 vs. 285 min/week, p = 0.61). The HKA of the FP was significantly lower (toward varus) than that of the REF (177.6° ± 2.4° vs. 179.0° ± 2.4°; p < 0.001). However, ICD did not significantly differ (FP: 17 ± 25 mm, REF: 13 ± 27 mm; p = 0.55). The football environment with frequent football exposure seems to have an influence on leg axis deviation in FP compared to REF. For prevention of knee osteoarthritis in FP, an advanced understanding of leg axis development in adolescent players is essential and, therefore, needs further research

Pathological Findings in Male and Female Semi-Professional Football Players from 11 to 14 Years—A Report of the Bavarian Football Association’s Pre-Participation Screening Program

Pre-participation screening (PPS) in professional junior football is common practice. However, football players (FP) from non-professional football clubs may also be exposed to health risks, both internal and musculoskeletal. Therefore, the Bavarian Football Association (BFV) implemented a cardiological and orthopedic screening program for semi-professional FP in 2014. The purpose of this study was to obtain and present epidemiological data of pre-adolescent and adolescent semi-professional FP, including cardiac pathologies, past injuries, and orthopedic disorders. This study represents a retrospective analysis of semi-professional FP aged 11 to 14 years participating in the PPS program from 2014 to 2018, including their medical history, cardiac risk profiles, and the results of undergoing orthopedic and sports cardiology examinations. Overall, 362 male and 162 female FP could be included. More than 20% of the FP indicated suffering from one or more medical conditions. Cardiac abnormalities were reported in 30 (5.7%) FP. Further cardiological diagnostics were recommended for 3% of the FP due to findings while undergoing the PPS. Orthopedic disorders could be detected in 51 (9.7%) FP. Of the reported injuries, 44.3% could be categorized as overuse injuries. In order to guarantee extensive preventive sports medical care for semi-professional junior FP, a PPS concept should include a basic orthopedic examination in addition to cardiological screening due to a high rate of overuse injuries and cardiac abnormalities among pre-adolescent and adolescent FP. Further studies are needed in junior football to gain epidemiological data on injury occurrence and cardiac abnormalities on an amateur level to evaluate possible PPS programs, even on an amateur level

Current Standards of Early Rehabilitation after Anterior Cruciate Ligament Reconstruction in German Speaking Countries - Differentiation Based on Tendon Graft and Concomitant Injuries

Background: Although anterior cruciate ligament reconstruction (ACLR) is a well-established procedure and is standardly performed by orthopedic surgeons all over the world, there does not seem to be a standard protocol for early rehabilitation. The purpose of this study was to give answers to the following questions: (i) Does (a) the use of a specific tendon graft, and (b) potentially additional therapy of concomitant pathologies influence surgeons’ choice of a distinct postoperative rehabilitation protocol after ACLR? (ii) To what extent do these rehabilitation recommendations differ? Methods: Retrospective analysis of currently used early rehabilitation protocols after ACLR in German-speaking countries (GER, AUT and SUI) was conducted. Rehabilitation criteria included weight bearing, range of motion (ROM), the utilization of braces, continuous passive/active motion therapy (CPM/CAM), rehabilitation training and sport-specific training. Tendon grafts were differentiated as hamstring (HAM) and bone–patellar tendon–bone grafts (BTB). Concomitant pathologies included meniscus injuries (+M) and unhappy triad injuries (+UTI). Results: Most of the surveyed protocols were differentiated according to the used tendon graft or additional therapy of concomitant injuries (ACLR-differentiated, n = 147 vs. ACLR without graft differentiation, n = 58). When comparing ACLR-HAM and ACLR-BTB, significant differences were found regarding weight bearing (p = 0.01), ROM (p = 0.05) and the utilization of braces (p = 0.03). Regarding ACLR+M, an overall significant decelerated rehabilitation could be detected. After ACLR+UTI-therapy, a significant delayed start to full weight bearing (p = 0.002) and ROM (p < 0.001) was found. Conclusions: Most orthopedic surgeons from German-speaking countries differentiate early rehabilitation after ACLR according to the tendon graft used and therapy of concomitant pathologies. No consensus about early rehabilitation after ACLR is available. However, tendencies for an accelerated rehabilitation after ACLR-BTB and a more restrained rehabilitation of multiple injured knees were detected

Pathological Findings in Male and Female Semi-Professional Football Players from 11 to 14 Years—A Report of the Bavarian Football Association’s Pre-Participation Screening Program

Pre-participation screening (PPS) in professional junior football is common practice. However, football players (FP) from non-professional football clubs may also be exposed to health risks, both internal and musculoskeletal. Therefore, the Bavarian Football Association (BFV) implemented a cardiological and orthopedic screening program for semi-professional FP in 2014. The purpose of this study was to obtain and present epidemiological data of pre-adolescent and adolescent semi-professional FP, including cardiac pathologies, past injuries, and orthopedic disorders. This study represents a retrospective analysis of semi-professional FP aged 11 to 14 years participating in the PPS program from 2014 to 2018, including their medical history, cardiac risk profiles, and the results of undergoing orthopedic and sports cardiology examinations. Overall, 362 male and 162 female FP could be included. More than 20% of the FP indicated suffering from one or more medical conditions. Cardiac abnormalities were reported in 30 (5.7%) FP. Further cardiological diagnostics were recommended for 3% of the FP due to findings while undergoing the PPS. Orthopedic disorders could be detected in 51 (9.7%) FP. Of the reported injuries, 44.3% could be categorized as overuse injuries. In order to guarantee extensive preventive sports medical care for semi-professional junior FP, a PPS concept should include a basic orthopedic examination in addition to cardiological screening due to a high rate of overuse injuries and cardiac abnormalities among pre-adolescent and adolescent FP. Further studies are needed in junior football to gain epidemiological data on injury occurrence and cardiac abnormalities on an amateur level to evaluate possible PPS programs, even on an amateur level

Early Functional Rehabilitation after Meniscus Surgery: Are Currently Used Orthopedic Rehabilitation Standards Up to Date?

Meniscus therapy is a challenging process. Besides the respective surgical procedure such as partial meniscectomy, meniscus repair, or meniscus replacement, early postoperative rehabilitation is important for meniscus regeneration and return to sport and work as well as long-term outcome. Various recommendations are available. However, the current literature lacks information concerning the actual early rehabilitation in daily routine recommended by orthopedic surgeons. Thus, the purpose of this study was to investigate currently used standard early rehabilitation protocols in the daily routine of orthopedic surgeons. This study investigated the recommendations and concepts for early rehabilitation after meniscus therapy given by German, Austrian, and Swiss orthopedic institutions. Standardized criteria such as weight bearing, range of motion, use of an orthosis, and rehabilitation training were analyzed according to the conducted surgical procedure: partial meniscectomy, meniscus repair, or meniscus replacement. The analysis of standard rehabilitation concepts for partial meniscectomy (), meniscus repair (), and meniscus replacement () showed significantly earlier functional rehabilitation in all criteria after partial meniscectomy in contrast to meniscus repair techniques (). In addition, significant restrictions were found in full weight bearing, full range of motion, and the use of braces. In summary, a wide range of recommendations for weight bearing, ROM, brace therapy, and mobilization is available, particularly after meniscus repair and meniscus replacement. Most concepts are in accordance with those described in the current literature. Further research is necessary to enhance the scientific evidence on currently used early rehabilitation concepts after meniscus therapy

Reduced performance after return to competition in ACL injuries: an analysis on return to competition in the ‘ACL registry in German Football’

Purpose ACL injuries are one of the most severe injuries in football, but medical consequences and performance outcomes after return to competition are only rarely investigated. Aim of this study was to analyse the time of return to competition (RTC) in German professional, semi-professional and amateur football. Also, this investigation highlights the rate of career ending and performance outcome after RTC in different playing levels by the measurement of playing level, performed matches and played minutes. Methods Database of this investigation is the ‘ACL registry in German Football’ with prospectively collected injury data. Between 2014 and 2018, four seasons in professional (1st–3rd league), semi-professional (4th–6th league) and amateur leagues (7th league) were analysed regarding the return to competition period and performance parameters. Data were collected for three subsequent seasons after injury and compared with the pre-injury and injury season. Data collection was performed using standardized methods. Results A total of 607 ACL injuries were registered during the 4-year period with a mean RTC time of 337.1 day (SD: 183). After primary ACL ruptures, the fastest RTC was found in professional football (247.3 days), while in semi-professional (333.5 d; p < 0.0001) and amateur football (376.2 d; p < 0.0001) a prolonged absence was detected. Re-ruptures occurred in 17.8% (n = 108) and showed similar trend with fastest RTC in professionals (289.9 days; p = 0.002). Within the first three seasons after injury, 92 players (36.7%) in semi-professional and 24 (20%) in professionals had to end their career. Keeping the level of play was only possible for 48 (47.5%) of professionals, while only 47 (29.6%) of semi-professionals and 43 (28.1%) of amateurs were able to. Only in professional football, no significant difference could be seen in the played minutes and games after 2 years compared to the pre-injury season. Conclusion Lower playing levels and re-ruptures are the main factors for a prolonged return to competition after ACL rupture in German football. Significant reduction in playing level and a high rate of career endings were found for all levels of play. However, only professional players were able to regain their playing minutes and games 2 years after injury, while lower classed athletes did not reach the same amount within 3 years. Level of evidence Level III