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The extracellular matrix derived from porcine small intestinal submucosa (SIS-ECM), an FDA-approved material currently used clinically for rotator cuff repair, has been shown to attract bone marrow-derived cells during in vivo remodeling of a subcutaneous implant and produce chemoattractant peptides following chemical degradation in vitro. The purpose of the present study was to determine if bone marrow-derived cells participate in the long-term remodeling of the Achilles tendon in a mouse model when repaired with SIS-ECM. A 2-mm gap was produced in the Achilles tendon of 40 chimeric mice produced to express green fluorescent protein (GFP) in all of their bone marrow-derived cells. Tendons were repaired by replacing the resected section with autologous tendon tissue or with a single layer sheet of lyophilized SIS-ECM. Four animals from each treatment group were sacrificed at 1, 2, 4, 8, and 16 weeks, and sections were harvested for histologic and fluorescence microscopy. Both groups showed accumulation of GFP-expressing marrow-derived cells at the site of tendon remodeling at 1 and 2 weeks that were associated with areas of angiogenesis and inflammation. By 16 weeks, the SIS-ECM-treated group showed GFP expressing cells throughout the remodeled tendon in the absence of any inflammatory response, while the autologous tendon repair group showed no GFP expressing cells within the tendon except for occasional cells in the lumen of blood vessels. An SIS-ECM scaffold used for tendon repair recruits a population of bone marrow-derived cells that participates in the long-term remodeling process. The ability of SIS-ECM to recruit a population of marrow-derived cells to the remodeling site may alter the default mechanism of tendon healing. The involvement of these cells in the remodeling process may explain in part the process of site specific constructive remodeling as opposed to scar tissue formation when the ECM is used as a biologic scaffold for tendon reconstruction., ((c) 2006 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Introduction: Femoral tunnel placement has a great influence on the clinical outcome after PCL reconstruction., Materials and Methods: Using a robotic/universal force moment sensor (UFS) testing system, we examined joint kinematics and in situ forces of human knees following soft-tissue single bundle PCL reconstruction fixed at the center of the femoral attachment., Results: Posterior tibial translation significantly increased at all flexion angles after transsection of the posterior cruciate ligament (p<0.05). PCL reconstruction resulted in significantly less posterior tibial translation at all flexion angles when compared to the PCL deficient knee (p<0.05). The differences in the in situ force between the intact ligament and the reconstructed graft were statistical significant (p<0.05)., Conclusion: Single bundle PCL reconstruction with a soft-tissue graft fixed at the center of the femoral attachment is able to reduce the posterior tibial translation significantly. However, it cannot restore kinematics of the intact knee and in situ forces of the intact PCL.

Background: Previous studies have identified the femoral attachment of the posterior cruciate ligament fibers as one of the primary determinants of fiber tension behavior. In addition, a double-bundle posterior cruciate ligament reconstruction has been shown to restore the intact knee kinematics more closely than does a single-bundle reconstruction., Hypothesis: An anterior tunnel position in double-bundle posterior cruciate ligament reconstruction restores the biomechanics of the normal knee more closely than does a posterior tunnel position., Study Design: Controlled laboratory study., Methods: Kinematics and in situ forces of human knees after double-bundle posterior cruciate ligament reconstruction with 2 different femoral tunnel positions (anterior vs posterior) were evaluated using a robotic/universal force-moment sensor testing system. Within the same specimen, the resulting knee kinematics and in situ forces were compared. For statistical analysis, 2-way analysis of variance repeated measures were performed., Results: The femoral tunnel position of the double-bundle hamstring graft had significant effect on the resulting posterior tibial displacement and in situ forces of the hamstring grafts. The anterior femoral tunnel position provided significantly less posterior tibial translation than did the posterior tunnel position. There was a tendency toward higher in situ forces of grafts fixed in the anterior tunnel when compared to the posterior position, but this difference was statistically not significant., Conclusion: An anterior position of the bone tunnels in double-bundle posterior cruciate ligament reconstruction restores the normal knee kinematics more closely than does a posterior position of the tunnels., Clinical Relevance: In double-bundle posterior cruciate ligament reconstruction, posterior placement of the tunnel should be avoided.

Fractures of the tibial head are severe injuries, characterized by enormous variety. Fractures can be classified into fractures of the tibial plateau, luxation fractures, and comminuted fractures. Due to the mechanism of injury luxation fractures are frequently associated with lesions of the menisci and intra- and extra-articular ligaments. Multiple factors can be etiologic for post-traumatic gonarthrosis: nonanatomic reduction of the joint surface, malalignment, and unaddressed associated injuries. Therefore in addition to diagnostic steps such as X-ray, CT scan, and MRI a sophisticated therapeutic regime is necessary. In cases with severely damaged soft tissue or unstable patients, the fracture should initially be reduced and fixed with an external fixator and the definite fixation should be performed in a second setting. Arthroscopically assisted treatment is reserved for fractures of the tibial eminence, crack fractures, and impression fractures. Comminuted and bilateral fractures can be addressed via different incisions. New locking plates with angular stability allow avoidance of bilateral plating in most situations. In specific cases such as compound fractures and for patients with low compliance, a hybrid fixator may be a well-chosen alternative.

Background: Few authors have investigated the effectiveness of preventive intervention in European team handball., Purpose: The aim of the present study was to evaluate the effects of a prevention program on the incidence of injuries in female European team handball players., Study Design: Prospective controlled study., Methods: Ten female handball teams (134 players) took part in the prevention program (1. Information about injury mechanism, 2. Balance-board exercises, 3. Jump training) while 10 other teams (142 players) were instructed to train as usual. Over one season all injuries were documented weekly., Results: Ankle sprain was the most frequent diagnosis in both groups with 11 ankle sprains in the control group and 7 ankle sprains in the intervention group (Odds ratio: 0.55, 95% confidence interval: 0.22-1.43). The knee was the second frequent injury site. In the control group 5 of all knee injuries were anterior cruciate ligament (ACL) ruptures (incidence: 0.21 per 1000 h) in comparison with one in the intervention group (incidence: 0.04 per 1000 h). Odds ratio was 0.17 with 95% confidence interval of 0.02-1.5., Conclusions: This study confirms that proprioceptive and neuromuscular training is appropriate for the prevention of knee and ankle injuries among female European team handball players.

Purpose: The aim of this study was to compare ultimate load, yield load, stiffness, and displacement after cyclic loading of a cross-pin technique and an interference screw technique for the fixation of bone-patellar tendon-bone (BPTB) grafts in anterior cruciate ligament (ACL) reconstruction., Type of Study: Biomechanical in vitro study., Methods: The devices tested were 2 2.7-mm biodegradable pins (RigidFix; Ethicon, Mitek Division, Norderstedt, Germany) and biodegradable interference screws (Absolute; Innovasive Devices, Marlborough, MA). Each device was used for the fixation of 10 8-mm, 9-mm, or 10-mm sized human BPTB grafts in tunnels drilled in bovine knees. Ultimate load, yield load, stiffness, and displacement after cyclic loading (1,000 cycles between 50 and 250 N) were then evaluated., Results: All 8-mm grafts that were fixed with cross-pins failed after a mean of 124 cycles of load. The 9-mm and 10-mm grafts survived the cyclic loading protocol. Yield load and maximum load of the 10-mm groups (cross-pin and interference screw) were significantly higher than that of the 9-mm groups. There was no significant difference in maximum load, yield load, and stiffness between the cross-pin and interference screw fixation technique for 1 graft size., Conclusions: The biomechanical data suggest that femoral fixation of 9-mm and 10-mm BPTB grafts using 2.7-mm biodegradable cross-pins leads to primary stability that is comparable to that of biodegradable interference screws. Fixation of 8-mm BPTB grafts using 2.7-mm biodegradable cross-pins had poor results., Clinical Relevance: The diameter of the bone block is the limiting factor for the final fixation strength and the cyclical survival when using cross-pins. We strongly recommend not using this technique for bone blocks smaller than 9 mm in diameter.

The aim of this review article is to give an overview of current knowledge on kitesurfing injuries. As part of a prospective study, the overall self-reported injury rate was 7.0 per 1000 h of practice. One fatal accident and 11 severe injuries occurred. The most commonly injured sites were foot and ankle, head, chest, and knee. Contusions, abrasions, and lacerations were amongst the most frequent injuries. None of the athletes suffering a head injury used a helmet; the board had been flung against the head by the elastic board leech in all cases. The most common injury situation was the jump. Fifty-six percent of the injuries were attributed to the inability to detach the kite from the harness. There was a tendency that athletes using a quick release system, which enables the surfers to detach the kite in emergency situations, sustained fewer injuries than athletes without such a release system. In conclusion, kitesurfing is a sport with a comparably high injury rate. Preventive measures can reduce the injury rate considerably.

Purpose: During the early postoperative period, the stability of the fixation of a hamstring graft to the bone tunnel is the primary factor in limiting rehabilitation. The aim of this study was to evaluate if the initial fixation strength of a new suspension screw is comparable to that of the biodegradable interference screw fixation technique in the hamstring reconstruction of the anterior cruciate ligament (ACL)., Type of Study: Experimental laboratory study., Methods: We evaluated the initial fixation strength of a biodegradable poly-L-lactide/tri-calcium phosphate (PLLA/TCP) screw that suspended the graft in the bone tunnel and compared it with the strength of an interference screw for fixation of hamstring grafts in ACL reconstruction using bovine knees. Single-cycle and cyclic loading tests were performed using a materials testing machine., Results: The suspension screw provided a significantly higher yield load and ultimate failure load than the interference screw. There was no significant difference in the stiffness of both techniques. The typical failure mode for the suspension screw was fracture of the screw and for the interference screw it was slippage of the graft past the screw. In cyclic testing, both methods of fixation ran out to 1,000 cycles up to 250 N with a mean displacement of 2.6 mm (range, 1.8 to 3.3 mm) for the suspension screw and 4.1 mm (range, 2.3 to 6.0 mm) for the interference screw. Only the grafts fixed with the suspension screw survived a protocol with 1,000 cycles up to 400 N., Conclusions: Our biomechanical data suggest that hamstring graft fixation using a biodegradable PLLA/TCP suspension screw provides an alternative to interference screw fixation., Clinical Relevance: Hamstring graft fixation using a suspension screw provides a reasonable alternative to interference screw fixation.

To overcome the disadvantages of interference-screw fixation of bone-patellar tendon-bone (BPTB) grafts, new fixation techniques for anterior cruciate ligament (ACL) grafts using biodegradable pins have been developed. The hypothesis of the present study was that cross-pin fixation techniques provide a primary stability that is comparable to that of interference screws. A biomechanical in vitro study was discussed. Human BPTB grafts of 8, 9 and 10 mm diameter were fixed in bovine knees with biodegradable cross pins (diameter: 2.0, 2.7 or 3.2 mm) or biodegradable interference screws. Stiffness and ultimate load were evaluated. For 9 and 10 mm BPTB grafts, no statistically significant difference in maximum load and stiffness was found between the four fixation techniques tested. For 8 mm bone blocks the maximum load of the 3.2 mm pins (274.2 N) was significantly lower than for the 2.0 mm pins (479.8 N) and the interference screws (504.0 N). Predominant failure mode in this group was bone-block fracture. Thicker grafts (9 and 10 mm) fixed with the 2.0 mm pins predominantly failed by implant fracture. Femoral fixation of 8, 9 and 10 mm BPTB grafts using cross pins leads to biomechanical properties that are comparable to biodegradable interference screws when tested by a single-cycle load to failure. Cross pins provide a rigid fixation for 9 and 10 mm BPTB grafts.

Introduction: Surgical reconstruction of the posterior cruciate ligament (PCL) is recommended in acute injuries that result in severe tibial subluxation and instability. The surgical outcome level may be affected by the tibial fixation site. In response to a 110-N posterior tibial load, kinematics and in situ forces of anatomical soft-tissue graft fixation in single-bundle PCL reconstruction using an interference screw fixation are significantly closer to those in the intact knee than with extracortical fixation with two staples., Materials and Methods: Using a robotic/universal force moment sensor (UFS) testing system, we examined joint kinematics and in situ forces of porcine knees following single-bundle PCL reconstruction fixed at two different tibial fixation sites: anatomical interference screw and extracortical fixation., Results: The site of the tibial graft fixation had significant effect on the resulting posterior displacement and in situ forces of the graft. Both PCL reconstruction techniques reduced the posterior tibial translation significantly. Proximal fixation techniques provided significantly less posterior tibial translation than extracortical fixation. Single-bundle PCL reconstruction with an interference screw showed higher in situ forces of the graft than the extracortical fixation., Conclusions: The kinematics and in situ forces of a single-bundle PCL reconstruction using an interference screw fixation technique are superior to the primary stability of an extracortical fixation with staples.

The aim of this study was to evaluate structural properties of native and elongated bovine anterior cruciate ligaments after the application of bipolar radiofrequency. Using a material testing machine typical load-elongation curves were used to determine the initial strength of untreated (group 1, n = 20) and elongated cruciate ligaments (group 2, n = 20) after treatment with bipolar radiofrequency (ArthroCare). After the application of a cyclic loading protocol (1000 x 400 N) elongation, yield load, maximal load, and stiffness were determined. Native ligaments served as a control group (group 3, n = 20). In both groups 4 mm reduction in length was caused by the application of radiofrequency. Elongation was significantly higher; yield load, maximal load, and stiffness of cruciate ligaments treated with radiofrequency (groups 1 and 2) were significantly reduced after the application of a cyclic loading protocol in comparison to the control group (p < 0.05). Group 2 ligaments showed the lowest values. The application of radiofrequency weakens the biomechanical properties of native and elongated cruciate ligaments significantly. When radiofrequency energy is used to shrink elongated cruciate ligaments, a nonaggressive rehabilitation protocol should be applied.

The first case of little league shoulder syndrome in a cricket player is reported. The condition has been reported in baseball pitchers and is characterised by a proximal humeral epiphyseolysis.

Neovascularization is involved in beneficial and detrimental processes of tendon pathology. We investigated the influence of repetitive motion on the expression of the most important angiogenic factor, the vascular endothelial growth factor (VEGF) in the 3T3 NIH fibroblast cell line and in cultures of rat Achilles tendon fibroblasts. Monolayers of subconfluently grown cells were stretched in rectangular silicone dishes with cyclic uniaxial movement. Strain was applied over 24 h varying the frequency (0.5-1 Hz). Fibroblasts (3T3 fibroblasts and rat Achilles tendon cultures) cultivated without the application of cyclic strain released measurable VEGF amounts into their culture supernatants. Cyclic stretching of the cells with a frequency of 1 Hz resulted in an increased expression of VEGF. A low frequency (0.5 Hz) reduced VEGF expression to control levels. RT PCR revealed VEGF 121 and VEGF 165 as the only splice forms that were induced by cyclic stretching. Western blot experiments could further show that cyclic stretching induced activation of the transcription factor HIF-1alpha. These results demonstrate that mechanical factors are involved in the regulation of VEGF expression in tendon tissue.

All-inside repair devices have been developed to overcome the disadvantages of conventional suture techniques (such as vein and nerve damage and increased OR time). The Contour Meniscus Arrow is a second generation of the first biodegradable all-inside implant, the Meniscus Arrow. The aim of this study was to compare the biomechanical properties of the Contour Meniscus Arrow to the first-generation Meniscus Arrow and vertical or horizontal suture techniques. In fresh frozen bovine menisci, initial fixation strength, stiffness and failure mode of four different meniscus refixation techniques (Meniscus Arrow, Contour Meniscus Arrow, vertical and horizontal 2-0 Ethibond suture techniques) were evaluated in a computer-based material-testing machine at a rate of 12.5 mm/s. Vertical meniscus sutures showed the highest initial fixation strength, followed by the horizontal suture technique and the Contour Arrow. The Meniscus Arrow showed inferior pull-out strength. Subjecting the different refixation techniques to cyclic testing decreased the fixation strength in all groups. The modified Meniscus Anchor (Contour Arrow) provides biomechanical properties that are superior (pull-out strength) or similar (stiffness) compared to the first biodegradable all-inside implant, the Meniscus Arrow. The pull-out strength of the Contour Arrow was comparable to the pull-out strength reported for horizontal meniscus sutures in the literature. These biomechanical characteristics of this new implant justify clinical use.

Introduction: The aim of the study was to achieve injury situations in European team handball with a video based method., Methods: A video tape containing 59 injuries of an Olympic handball tournament were analyzed by two observers (sports-scientist, orthopaedic surgeon). The analysis was based on a method previously published by Teitz, which was developed to analyze ACL-injuries. The parameters body region, field position, contact/non-contact, offense/defense, field player/goal keeper were mainly used., Results: The most injuries were localized at the head (N = 20), the lower limb (N = 15), thorax and abdomen (N = 9) and the upper limb (N = 9). Concerning the field, the most injuries were in the midfield (N = 20), followed by the left (N = 13) and right (N = 9) outside position. The injured players were mostly in the offense (84 %), and in the majority of cases the field players were affected (97 %). 86 % of the injuries accomplished by contact., Conclusion: The head has a high risk, predominantly of contact injury. Contact-injuries could only be reduced by strict decisions of the referees. Non-contact injuries should be prevented by a special coordinative training.

Background: To date, the pattern and rate of kitesurfing injuries are largely unclear., Hypothesis: The pattern and rate of kitesurfing injuries are comparable to that of contact sports such as football and soccer., Study Design: Prospective study., Methods: The study was conducted over a 6-month period of 1 season and included 235 kitesurfers., Results: The number of self-reported injuries was 124, for an overall self-reported injury rate of 7 per 1000 hours of practice. One fatal accident (polytrauma) and 11 severe injuries occurred during the study period (2 knee ligament injuries and 9 fractures at various sites). The most commonly injured sites were the foot and ankle (28%), skull (14%), chest (13%), and knee (13%). Fifty-six percent of the injuries were attributed to the inability to detach the kite from the harness in a situation involving loss of control over the kite. There was a tendency for athletes using a quick-release system to sustain fewer injuries than athletes without such a release system., Conclusion: Kitesurfing can be considered a high-risk sport., Clinical Relevance: The use of a quick-release system that enables the surfers to detach the kite in case of an accident might aid in the prevention of injuries.

Background: The most common site of rupture of the posterior tibial tendon is the retromalleolar region where the tendon changes its direction of pull. The aim of this study was to characterize the tissue of the gliding zone of the tibialis posterior tendon to gain further knowledge about possible structural causes for spontaneous tendon rupture., Methods: Light microscopy, transmission electron microscopy and immunohistochemical methods were used to describe the structure of the human tibialis posterior tendon., Results: In the region where the tendon wraps around the medial malleolus, the structure of the tissue changes from the typical structure of a traction tendon. The superficial zone which was directed towards the pulley tissue had the structure of fibrocartilage with a specific three-dimensional collagen fibril texture. Transmission electron microscopy showed chondrocytes with a felt-like pericellular matrix that increased in size towards the gliding surface. The extracellular matrix of the fibrocartilage was rich in acid glycosaminoglycans and stained intensively with alcian blue at pH 1. Immunohistochemical staining of cartilage-specific extracellular matrix components such as type II collagen, chondroitin-4-sulphate, chondroitin-6-sulphate, keratan sulphate and aggrecan was positive., Conclusion: The location of the fibrocartilage corresponds to the region where the tibialis posterior tendon wraps around the medial malleolus, which serves as a pulley. According to the theory of 'causal histogenesis', the stimulus for the development of fibrocartilage within dense connective tissue is intermittent compressive and shear stress. The fibrocartilaginous region is the region where most spontaneous ruptures of the tibialis posterior tendon occur. Due to its structure, the fibrocartilaginous region may be more vulnerable to repetitive tensile microtrauma; degeneration may occur due to the poor repair response of the avascular fibrocartilaginous tissue.

Evidence suggests neovascularization is involved in the etiology of spontaneous Achilles tendon rupture. Therefore we investigated expression of the receptors of one of the most important angiogenic factors, the vascular endothelial growth factor in normal and pathologic human Achilles tendons by immunohistochemical and molecular biology methods. Light microscopy showed degenerative changes in all spontaneously ruptured tendons with a higher vascular density compared with controls of healthy tendons from a cadaver. The vascular endothelial growth factor receptors-1 and 2 could be immunostained in endothelial cells of ruptured and fetal tendons, but not in normal tendons. Reverse transcription-polymerase chain reaction showed messenger ribonucleic acid of both receptors are expressed in ruptured and fetal tendons but not in normal tendons. These results prove the reexpression of the major receptors for the angiogenic peptide vascular endothelial growth factor, the vascular endothelial growth factor receptor-1, and the vascular endothelial growth factor receptor-2 in ruptured and fetal tendons and support our theory that high vascular density is associated with the pathogenesis of tendon degenerations. Inhibiting angiogenesis could be a new approach in the therapy of degenerative Achilles tendon disease.

Purpose: To determine the effects of increasing anterior-posterior (A-P) tibial slope on knee kinematics and in situ forces in the cruciate ligaments., Methods: Ten cadaveric knees were studied using a robotic testing system using three loading conditions: (1) 200 N axial compression; (2) 134 N A-P tibial load; and (3) combined 200 N axial and 134 N A-P loads. Resulting knee kinematics were determined before and after a 5-mm anterior opening wedge osteotomy. Resulting in situ forces in each cruciate ligament were determined., Results: Tibial slope was increased from 8.8 +/- 1.8 degrees to 13.2 +/- 2.1 degrees, causing an anterior shift in the resting position of the tibia relative to the femur up to 3.6 +/- 1.4 mm. Under axial compression, the osteotomy caused a significant anterior tibial translation up to 1.9 +/- 2.5 mm (90 degrees ). Under A-P and combined loads, no differences were detected in A-P translation or in situ forces in the cruciates (intact versus osteotomy)., Conclusions: Results suggest that small increases in tibial slope do not affect A-P translations or in situ forces in the cruciate ligaments. However, increasing slope causes an anterior shift in tibial resting position that is accentuated under axial loads. This suggests that increasing tibial slope may be beneficial in reducing tibial sag in a PCL-deficient knee, whereas decreasing slope may be protective in an ACL-deficient knee.

Purpose: We evaluated the initial bone-patellar tendon-bone (BPTB) graft fixation strength of biodegradable pins compared with interference screws in anterior cruciate ligament reconstruction using bovine knees., Type of Study: Biomechanical in vitro study., Methods: Ten BPTB grafts from human donors fixed with 2 biodegradable 2.7-mm pins (Rigid Fix; Ethicon, Mitek Division, Norderstedt, Germany) crossing the bone block perpendicular and 10 BPTB grafts fixed with conventional biodegradable interference screws (Absolute Absorbable Interference Screw; Innovasive Devices, Marlborough, MA) underwent ultimate single-cycle failure loading at a rate of 200 mm/min. The grafts were fixed to bovine tibia to simulate young human femoral bone density. Failure mode, displacement before failure, and ultimate failure load were tested with a testing machine. The pullout force was in line with the bone tunnel to simulate a worst case scenario., Results: The failure mode for cross pins was either fracture of the bone block (5 specimens) or fracture of the articular pin (5 specimens). The failure mode for interference screws was slippage past the screw in all specimens. In the single cycle loading test, the mean yield load for the biodegradable pins was 400.2 (+/- 122.4) N, maximum load, 524.6 (+/- 136.6) N, with a mean stiffness of 155.2 (+/- 32.4) N/mm. The yield load at failure for the interference screw was 402.7 (+/- 143.9) N, maximum load 515.7 (+/- 168.5) N with a mean stiffness of 168 (+/- 42) N/mm., Conclusions: Fixation of a BPTB graft with 2 biodegradable 2.7-mm pins (Rigid Fix) leads to primary stability that is comparable to fixation with biodegradable interference screws.

Background: Angiogenesis, the formation of new blood vessels from pre-existing vessels, is an essential step in the process of tendon healing and tendon graft remodelling, e.g. after anterior cruciate ligament reconstruction. To address the question of whether platelet-derived growth factor (PDGF) could influence vascular endothelial growth factor (VEGF) expression in tenocytes, we challenged primary cultures of rat tenocytes with different stimulators (hypoxia, PDGF) and measured their VEGF secretion., Methods: To measure the VEGF secretion and the effect of PDGF, we used cell culture and stimulation of rat tenocytes (2-5 days old), immunohistochemistry as well as enzyme-linked immunosorbent assay (ELISA)., Results: Tenocytes cultivated under normal oxygen pressure released measurable amounts of VEGF into their culture supernatants. Stimulation with PDGF, a cytokine that activates mitogen-activated protein kinases, raised VEGF secretion 2-fold. Hypoxic conditions alone (5% O(2)) raised VEGF secretion only 2-fold. However, the combination of cytokines and hypoxia increased VEGF production 5-fold, apparently a synergistic effect., Conclusion: These data are useful to further our understanding of angiogenesis in tendon healing and tendon graft remodelling after ACL reconstruction.

Background: The pathogenesis of Achilles tendon rupture remains unclear, but vascular patterns may play an important role. Hypoxia is considered to be an important factor in the aetiology of tendon degeneration., Methods: Statements from the literature regarding the vascularization of the Achilles tendon are controversial. We determined the vascular density of the Achilles tendon using a new method involving antibodies against laminin, a component of the basement membrane., Results: The blood supply of the Achilles tendon mainly arose from the anterior paratenon of the tendon from which vessels run into the tendon. The proximal part of the tendon was supplied by a recurrent branch of the posterior tibial artery, while the distal part of the tendon was vascularized by the rete arteriosum calcaneare, supplied by the fibular and posterior tibial arteries. An avascular area could be seen close to the insertion of the tendon to the calcaneus. Three regions with different vascular density could be determined in the Achilles tendon. The distal part of the Achilles tendon had a vascular density of 56.6 vessels/cm(2). In the middle part of the tendon, the vascular density was much lower: 28.2 vessels/cm(2). The proximal part of the tendon had a vascular density of 73.4 vessels/cm(2)., Conclusion: The reduced vascularization in the tendon waist may be a predisposing factor for degeneration and spontaneous rupture of the human Achilles tendon.

Background: The Achilles tendon is one of the most common sites of tendon injury and rupture. One of the early events of wound healing is angiogenesis, in which neovascularization prompts delivery of inflammatory cells and fibroblasts to the wound site. Angiogenesis is controlled by a variety of mitogenic, chemotactic, or inhibitory peptides and lipid factors that act on invading endothelial and smooth muscle cells. One of the most important angiogenic factors is the vascular endothelial cell growth factor (VEGF), a glycosylated protein of 46-48 kDa composed of two disulfide-linked subunits., Methods: We therefore investigated the expression of VEGF during healing of artificial lesions of the Achilles tendon in a sheep model by immunohistochemical, biochemical, molecular, and cell biology methods. Two groups were created, the Achilles tendon was tenotomized, and the animals were killed at 3 and 24 weeks. Each group consisted of 6 specimens. Six animals which did not undergo surgery served as controls., Results: VEGF could be immunostained in tenocytes of ruptured but not in normal adult tendons. At microvessels, the receptors VEGFR-1 (flt-1) and VEGFR-2 (KDR) could also be visualized. High VEGF levels in ruptured and negligible levels in normal Achilles tendons could be confirmed and quantified by enzyme-linked immunoassay (ELISA). The highest VEGF concentrations were found in ruptured tendons, whereas the VEGF content in healthy adult tendons was negligible. Interestingly, the VEGF concentration of the original tendon stump was higher after 3 weeks than that of the newly regenerated tendon tissue. However, this difference was not significant (p>0.05). Reverse transcription-polymerase chain reaction (RT-PCR) showed that the splice variants VEGF(120 )and VEGF(164) are expressed at 3 weeks and 24 weeks, respectively., Conclusion: These results prove the presence of the splice variants VEGF(120 )and VEGF(164) in ruptured tendons during the healing process. The demonstrated up-regulation of VEGF in intrinsic tenocytes suggests a role for VEGF in mechanisms of angiogenesis and Achilles tendon repair. Further research is needed to evaluate if VEGF might be a possible tool to enhance the process of tendon healing.

Aim of this study was to analyse the mechanisms of windsurfing injuries. For this purpose we performed a internet based survey among 327 windsurfers in Germany. Overall 630 accidents have been registered among all 327 athletes during the 2000 season. The majority of injuries were classified as minor injury. The most common injury was the bruise. 70 participants reported fractures, 26 participants ruptured a ligament. 280 injuries required medical treatment; in 67 cases even surgical treatment was necessary. The majority of accidents happened at wind power of 5-6 Beaufort after 2 hour exercise. A technical mistake was the most frequent cause for the accident. The most dangerous manoeuvres were difficult jumps (e. g. front loop, backward loop, 70 injuries). In 46 cases the weather conditions were underestimated. Only 10 windsurfers reported about broken material as cause for the injury. One half of the injuries happened in wave conditions. The analysis of injury mechanisms allows conclusions regarding injury prevention. A longer break after 60 minutes windsurfing might help to prevent injuries due to poor physical fitness. After one hour windsurfing without a break training of difficult manoeuvres should not be performed. The use of a helmet might prevent head injuries during training of difficult jumps. "Overpower situations" should be prevented by choosing the right board and sail size.

Introduction: Aim of the study was to elucidate epidemiological aspects and injury mechanisms in juvenile team handball., Method: A standardized questionnaire was used to evaluate the injuries of 100 juvenile players (50 male, 50 female, year of birth 1982/83)., Results: A total of 130 injuries were recorded of 73 players. Most of the injuries (73.1%) occurred between the age of 15 and 18. Approximately two thirds of the injuries (69.2%) occurred in a competition and most of them in an offensive situation. Backcourt players (29.0%), line players (27.5%), and goalkeepers (17.0%.) were the player positions to be most injured. Female goalkeepers were three times more often injured than male ones at the same age. Most injuries applied to the foot and the ankle (32.0%), followed by the finger joint (26.9%) and the knee (24.6%). The most frequent ankle injuries were ruptures of the lateral ankle ligaments. The knee joint was affected by the most severe injuries with the need of surgical therapy. The most common injury concerning the knee joint was rupture of the anterior cruciate ligament (ACL). Eleven ACL tears were recorded in the age between 15 and 18 years (12-14 years: 1; 8-12 years: 0). The most typical game situation at the point of injury was catching a ball (38.5%), contact situation with the opponent (34.5%), or landing after a jump (26.2%)., Conclusions: This study allows conclusions concerning prevention of injuries in juvenile team handball. There is apparently a difference in muscle strength and coordination of the youth handball player, especially at the age of 15-18 years, which has to be addressed. Therefore the authors recommend a proprioceptive training program as well as exercises to improve jumping techniques. Special strengthening training for the finger muscles might help to prevent finger injuries. The frequency of contact injuries underlines the importance of a "fair play" campaign among young players.

The flexor hallucis longus is the most common site of lower extremity tendon disorders in ballet dancers. Reduced vascularity is an important factor contributing to tendon degeneration and rupture under strain. A study was conducted on the vascular pattern of the human flexor hallucis longus tendon with injection techniques and immunohistochemically by using antibodies against laminin. Blood supply arose from the posterior tibial and the medial plantar artery. Peritendinous blood vessels penetrated the tendon and anastomosed with a longitudinally oriented intratendinous network. Injection specimens and immunohistochemistry revealed one avascular zone in which the tendon passed behind the talus and a second in which the tendon wrapped around the first metatarsal head. These are the most typical areas for tendon degeneration and rupture.

Introduction: Fractures of the wrist and forearm are the most frequent injuries in Inline-Skating. Clinical experience has shown that these injuries can be prevented the use of wrist protectors. But various authors have shown that fractures can also occur despite the use of wrist protectors. Aim of this study was to examine different wrist protectors in a biomechanical set up., Method: A standardized trauma was simulated using an artificial hand with a certain weight. The forces with or without protective devices have been recorded by a force moment sensor. The results of different protectors have been compared., Results: A mean force of 956 N was measured without the use of a protective device. With the application of a wrist protector these forces were reduced between 4 and 20 %. The best values have been reached with models with a strong base plate., Conclusions: The results of the present study may explain the clinical observation that wrist and forearm fractures can occur despite the use of a wrist guard. The protective effect of a wrist protector depends highly on the model that is used.

Background: Angiogenesis is important for the remodeling of autologous tendon grafts. A sheep model was used to examine the expression of the angiogenic peptide vascular endothelial growth factor (VEGF) in autologous tendon grafts after anterior cruciate ligament (ACL) reconstruction., Methods: Merino sheep underwent ACL reconstruction with an autologous Achilles tendon split graft. VEGF and its receptors, the Fms-like tyrosine kinase receptor (FLT-1, VEGFR-1) and the kinase insert domain-containing receptor KDR (VEGFR-2/FLK-1) were detected immunohistochemically. Reverse transcription-polymerase chain reaction (RT-PCR) was performed to detect which of the different VEGF splice forms are expressed during ACL remodeling., Results: At 6 weeks, light microscopy showed zones with hypocellular necrotic graft tissue in the central part surrounded by hypercellular and hypervascularized reparative tissue invading the former graft tissue from the periphery. In contrast to the necrotic tissue, all cell types of the reparative tissue labeled strongly positive for VEGF. The VEGF receptors FLT-1 and KDR could be detected on endothelial cells of blood vessels. At 12 weeks, the complete graft diameter showed an increased vascular density (anti-factor VIII immunoreactivity), but zones of non-remodeled former graft tissue could not be found. Fusiform fibroblasts labeled strongly for VEGF. At 24 weeks, VEGF immunostaining decreased, and at 52 and 104 weeks, the grafts were largely VEGF-negative. RT-PCR supported the immunohistochemical results regarding VEGF expression and showed further that the splice variants VEGF(120 )and VEGF(164) are expressed during angiogenesis during the remodeling of tendons., Conclusion: We conclude that the angiogenic peptide VEGF plays a role in tendon graft remodeling.

Background: A ganglion can arise as a cystic lesion from a tendon sheath or a joint capsule and contain a glassy, clear, and jelly-like fluid. They can occur within muscles, menisci, and tendons. Intra-articular ganglion cysts of the knee joint are rare. We report on three ganglion cysts of the cruciate ligaments: Two were intercruciate, and one was located around the posterior cruciate ligament., Methods: The clinical diagnosis was established using magnetic resonance imaging. All patients were treated successfully using arthroscopic debridement by basket punch and shaver. Subsequent histological examination confirmed the diagnosis., Results: All three patients were asymptomatic at the postoperative follow-up of 16-36 months., Conclusion: A review of the literature reveals a controversial discussion about the clinical significance as well as the etiology of ganglion cysts arising from the cruciate ligaments. These case reports show that an intra-articular ganglion cyst of the cruciate ligaments is difficult to diagnose. A cyst does not necessarily have to be associated with specific clinical symptoms or a previous trauma. Preoperatively, MRI is essential when diagnosing ganglion cysts of the knee joint. An intra-articular ganglion cyst of the knee joint can be successfully treated by arthroscopy.

Introduction: Injuries of the lower extremity lead to disability to perform sports and may cause degenerative changes of the joints. Hence, we developed a specific injury prevention programme for European team handball and tested this programme in a prospective study., Method: One handball team (2 nd division) performed a proprioceptive and neuromuscular training during the preseason. The programme consists of 3 different components: 1. Information on injury mechanisms, 2. Proprioceptive training, and 3. Jump training. During the season the exercises have been continued with lower intensity. Another handball team which performed no injury prevention training served as control. Injuries were recorded in a prospective manner. In a retrospective arm of the study we compared the frequency of severe injuries of the training season with the frequency of severe injuries during the last season., Results: In comparison to the last year no player from the prevention training team suffered a severe injury of the ankle or the knee. During the last season three athletes ruptured their anterior cruciate ligament. In the untrained control group one athlete suffered from an ACL rupture and one athlete had a rupture of the lateral ankle ligaments. These findings have no statistical significance because of the low number of individuals investigated. However, the incidence of light and medium injuries was significantly lower in the injury prevention group., Conclusions: This study demonstrates that proprioceptive and neuromuscular training is appropriate for the prevention of lower extremity injuries. Prevention strategies should be included in routine handball training programmes.