Jochen Paul

Technische Universität München, München, Bavaria, Germany

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Publications (14)31.75 Total impact

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    ABSTRACT: There are limited data regarding activity after osteochondral transplantation of the talus in orthopaedic publications. Osteochondral transplantation of the talus is a clinically successful treatment and enables patients to pursue regular and ongoing recreational sporting activities. Case series; Level of evidence, 4. One hundred thirty-one patients were retrospectively analyzed to determine their sporting and recreational activities at an average of 60 ± 28.4 months postoperatively (range, 24-141 months). The clinical evaluation included the Tegner activity scale, the Activity Rating Scale (ARS), and a visual analog scale (VAS) for pain. The VAS illustrated significant preoperative to postoperative improvements (6.3 to 2.7; P < .001). Regarding sporting activity, 96.9% of the patients were engaged in sports during their lifetimes compared with 83.8% the year before surgery and 89.3% at the time of survey. The Tegner score dropped from 5.9 preoperatively to 5.0 after surgery (P = .001), and the ARS decreased from 8.9 preoperatively to 6.8 postoperatively (P = .003). The sports frequency and the duration of activities did not significantly change after surgery: 1.7 ± 2.0 (range, 0-8; P = .053) and 4.2 ± 3.8 hours (range, 0-30 hours; P = .052), respectively. The number of actual reported different sports disciplines was unchanged in comparison to the year before surgery (3.7 ± 2.9; range, 0-12). The top 10 cited sports activities did not change for the lifetime, preoperative, and postoperative periods but illustrated an altered order. Although the overall satisfaction with the surgery was good, 15% of our patients were only partially satisfied, and 14% were not satisfied with the procedure. Patients engage in fewer, less frequent sporting activities when a symptomatic osteochondral lesion (OCL) at the talus is present. Talar osteochondral transplantation shows good clinical midterm results and allows patients to return to sporting activity. However, we found patients modify their postoperative sporting activities, and we noted a reduction of participation in high-impact and contact sports.
    The American journal of sports medicine 01/2012; 40(4):870-4. · 3.61 Impact Factor
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    ABSTRACT: The osteochondral autograft transfer is a commonly used technique for the treatment of osteochondral lesions of the ankle. It allows for the repair of the cartilage defect and the underlying subchondral damage in one procedure. An autologous graft, which is composed of hyaline cartilage on top of a bony cylinder, is transplanted into the defect area on the talus. The most frequently used donor site for the graft is the nonweight-bearing area of the ipsilateral knee joint: the most proximal portion of either the lateral or the medial femoral condyle. This technique has shown promising mid-term results in the treatment of circumscribed osteochondral lesions, and patients have been able to return to sports after the procedure. Unlike bone marrow-stimulating techniques, autologous grafts provide a hyaline articular cartilage matrix for the defect area. The transplanted chondrocytes can potentially maintain the matrix and provide a permanent chondral surface. Potential donor site morbidity has been discussed in the literature, but only in rare cases, does this seem to limit patients.
    Techniques in Foot & Ankle Surgery 11/2011; 10(4):144–147.
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    ABSTRACT: Posterior shoulder dislocations (PSDs) comprise a small subset of shoulder dislocations, and there are few evidence-based treatment protocols and no actual algorithm for the treatment of PSDs available in the literature. This article provides a systematic review of the literature, as well as an overview of clinical and radiologic diagnostic techniques, and presents an algorithm for treatment of PSDs, including minimally invasive treatment options. For a systematic review of current literature, a systematic search was performed in the Medline and Cochrane databases. Journal articles published between January 1940 and June 2010 were taken into account. Studies that only existed as abstracts were not included in the analysis. Broad exclusion criteria consisted of radiologic reports, review articles, case reports, and technical notes. Refined exclusion criteria consisted of a minimum of 4 patients with PSDs operated on by the same surgical technique and clinical outcome documented by a functional shoulder score. The final set of articles for evaluating closed or open techniques included 5 prospective case series and 6 retrospective studies. Within this group, there was no study with a level of evidence higher than Level IV. We present a descriptive comparison of these studies because of the heterogeneity and/or number of patients and the level of evidence. Case reports illustrate the different surgical approaches according to the literature. PSDs are still a challenge for the treating physician. There are few articles available about PSDs in evidence-based literature, with a limited number of cases. Our algorithm provides guidelines for decision making including minimally invasive treatment options according to the available literature. Level IV, systematic review of Level IV studies.
    Arthroscopy The Journal of Arthroscopic and Related Surgery 09/2011; 27(11):1562-72. · 3.10 Impact Factor
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    ABSTRACT: Osteochondral lesions of the ankle are a common injury after ankle sprains, especially in young and active patients. The Osteochondral Autograft Transfer System (OATS) is the only 1-step surgical technique designed to replace the entire osteochondral unit. This study was conducted to evaluate the long-term clinical and radiographic outcomes of the OATS procedure for the talus and compare the results of patients who have had prior surgical interventions with patients for whom OATS represents the primary surgical treatment. Case series; Level of evidence, 4. The authors retrospectively analyzed 26 talus OATS procedures (25 patients) with an average follow-up of 84 months (range, 53-124 months); 9 patients had OATS as a second surgical intervention. The patients completed the American Orthopaedic Foot & Ankle Society (AOFAS) and Tegner scores plus the visual analog scale (VAS) preoperatively and at follow-up. Magnetic resonance imaging examinations were conducted on a 1.5-T whole-body magnet that assessed transplant congruency, adjacent surface of the talus, the corresponding distal tibia, and joint effusion. The authors found significant increases for the AOFAS score (50 to 78 points, P < .01) and the Tegner score (3.1 to 3.7, P < .05) and a significant decrease for the VAS (7.8 to 1.5, P < .01) from preoperative to postoperative. Patients with normal integration or minor incongruity of the transplant on magnetic resonance imaging (81%) had significantly better AOFAS scores (P = .03). Other magnetic resonance imaging criteria did not predict clinical results. Patients for whom OATS represented a second procedure had significantly worse clinical AOFAS and Tegner scores plus a higher VAS. Long-term clinical and magnetic resonance imaging results after osteochondral transplantation are good and patients significantly benefit from this surgery. Magnetic resonance imaging should not be a routine control but appears to be indicated when clinical symptoms persist after osteochondral transplantation.
    The American journal of sports medicine 03/2011; 39(7):1487-93. · 3.61 Impact Factor
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    ABSTRACT: The purpose of this retrospective study was to investigate the rate of non-union after medial open-wedge high tibial osteotomy (HTO) with the Tomofix(®) plate. In addition, risk factors with a possible influence on the development of a non-union were analysed. Between 2006 and 2008, a total of 186 medial open-wedge HTOs were performed in 182 patients. Ten cases of non-union (5.4%) were recorded. Risk factors with a statistically significant influence on the development of a non-union included smoking, body mass index and fracture of the lateral cortical hinge. No influence was detected for the factors age, degree of correction, concomitant diseases, postoperative complications, drug use, additionally performed procedures and use of a temporary lag screw. Within this study, it could be demonstrated that the rate of non-union in medial open-wedge HTO is not higher than in the lateral closed-wedge technique. Concerning the detected risk factors, the importance of the preservation of the lateral cortex is emphasised. In addition, it is necessary to discuss the risk of non-union with smokers and overweight patients when planning the therapy. Finally, it should be considered to perform iliac crest bone grafting in these high-risk patients a priori.
    Knee Surgery Sports Traumatology Arthroscopy 03/2011; 19(3):333-9. · 2.68 Impact Factor
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    ABSTRACT: Open capsulolabral repair is still considered the standard revision procedure for a failed anterior shoulder instability repair. To date, only a few studies have evaluated the outcome of arthroscopic revision instability repair. This study was undertaken to assess the clinical outcome and postoperative sports activity level of arthroscopic revision stabilization using defined inclusion criteria and a standardized operative revision technique. Case series; Level of evidence, 4. Fifty-six patients with recurrent anterior shoulder instability after an anatomic index procedure (open or arthroscopic) were included in the study. Arthroscopic revision repair was performed by a single surgeon using standardized suture anchor repair technique via an anteroinferior 5:30-o'clock approach. Patients were evaluated after a mean follow-up of 37 months (range, 25-72 months) with the Rowe, the Constant score, and the Simple Shoulder Test (SST). Return to sports, including sports level and discipline, were evaluated with a sports activity assessment tool. For the revision repair, a minimum of 3 anchors were placed in the lower glenoid half. Recurrent instability after the revision procedure was found in 6 cases (11%). There were 4 recurrent instability cases caused by trauma and 2 atraumatic cases. Arthroscopic revision repair did not result in an additional loss of external rotation or additional subscapularis muscle insufficiency. The Rowe and Constant scores and the SST were significantly improved by the procedure. Eighty-six percent of the patients rated their result as good or excellent. Sports activity level was significantly improved by the procedure and the majority of patients returned to their previous sports level. Arthroscopic capsulolabral revision repair via the anteroinferior 5:30-o'clock approach achieves results comparable with open revision repairs with a low recurrent instability rate. Arthroscopic revision repair reached a high patient satisfaction, good clinical outcomes, and a high rate of return to sports. The results suggest that arthroscopic revision repair is a viable treatment option for selected patients with a failed index repair.
    The American journal of sports medicine 02/2011; 39(3):511-8. · 3.61 Impact Factor
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    ABSTRACT: Valgus-producing open-wedge high tibial osteotomy is an established treatment for varus malalignment and medial osteoarthritis, with reproducible results in the frontal plane. However, an undesirable but often accepted increase in posterior tibial slope and decrease in patellar height are still routinely seen. To evaluate the influence of valgus open-wedge high tibial osteotomy on posterior tibial slope and patellar height when special techniques are used to minimize unwanted changes. Case series; Level of evidence, 4. Twenty-five patients, 3 women and 22 men (mean age, 40.2 years), underwent valgus open-wedge high tibial osteotomy. Several technical steps were taken to prevent an increase in posterior tibial slope during the osteotomy. To minimize patellar height changes, the tibial tuberosity was left on either the proximal or distal fragment, depending on the desired patellofemoral effect. The medial and lateral posterior slope was measured using the proximal posterior cortex as a reference; the patellar height was assessed with the Caton-Deschamps Index and compared on preoperative and postoperative radiographs. No significant posterior tibial slope changes were observed. Patellar height increased with both types of tibial tuberosity osteotomy. With the proximal osteotomy, the Caton-Deschamps Index increased from 0.95 to 0.97; with the distal osteotomy, it increased from 0.89 to 0.95. The change was not significant with either osteotomy. The posterior tibial slope did not change on the medial side, measuring 4.2 preoperatively and postoperatively. The lateral slope decreased from 5.4 to 5.1. There was no correlation between the correction in the coronal plane and the changes in the sagittal plane. Open-wedge high tibial osteotomy can be performed without significant changes in patellar height or posterior tibial slope if specific intraoperative methods are used to prevent their occurrence. Analysis and control of sagittal changes in valgus open-wedge high tibial osteotomy should reduce the incidence of unwanted changes in patellar height and posterior tibial slope.
    The American journal of sports medicine 01/2011; 39(4):851-6. · 3.61 Impact Factor
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    ABSTRACT: Valgus high tibial osteotomy (HTO) may be associated with changes in the patellar height and posterior tibial slope. Patellar height increases and posterior tibial slope decreases after closed-wedge HTO, whereas patellar height decreases and tibial slope increases after open-wedge osteotomy. Cohort study; Level of evidence, 3. Lateral radiographs of 100 knees were assessed for patellar height (PH) (Insall-Salvati index [ISI], Caton-De Champ index [CDI], and Blackburne-Peel index [BPI]) as well as posterior tibial slope. Measurements were done before HTO (50 closed wedge [CW], 50 open wedge [OW]), direct postoperatively, and before removal of the hardware. In the CW group, all 3 PH indices were increased direct postoperatively and at removal of the hardware, with changes in CDI and BPI being significant (P<.05). The effect size (ES) for the direct postoperative PH increase was medium (ES = 0.48) according to CDI. In the OW group, all 3 indices showed a significant (P <.05) PH decrease direct postoperatively and at hardware removal. The ES for the direct postoperative PH decrease was large according to CDI (ES = 0.92) and BPI (ES = 0.80). There were no significant changes between the 2 follow-up measurements (P > .05) with a small ES each. Posterior tibial slope showed a significant (P <.05) decrease of 3.1 degrees +/- 3.4 degrees after CW HTO and a significant (P <.05) increase of 2.1 degrees +/- 3.6 degrees after OW HTO direct postoperatively. These changes did not change at the second follow-up. In CW HTO, the correlations between frontal plane correction and PH changes were moderate (CDI: r = .57; BPI: r = .64). In OW HTO, these correlations were weak (CDI: r = .44; BPI: r = .46). According to ISI, there was no correlation (CW: r = .11; OW: r = .16). There was no correlation between PH changes and slope changes (CDI) and no correlation between frontal plane HTO correction and slope changes in both CW and OW HTO. The results confirm our hypothesis for PH and posterior tibial slope changes after valgus HTO. However, there is no strong correlation between PH changes and the degree of frontal plane HTO correction. The incidence of patella infera increases after OW HTO, whereas the incidence of patella alta increases after CW HTO. Therefore, we recommend performing CW HTO or OW HTO with the tuberosity left at the proximal tibia in cases of patellofemoral complaints or patella infera. Neither technique leads to patellar lowering. It should be borne in mind that PH and posterior tibial slope may have been altered before planning total knee replacement after HTO.
    The American journal of sports medicine 02/2010; 38(2):323-9. · 3.61 Impact Factor
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    ABSTRACT: The purpose of this study was to determine inter- and intraobserver variability of MR arthrography of the shoulder in the detection and classification of superior labral anterior posterior (SLAP) lesions. MR arthrograms of 78 patients who underwent MR arthrography before arthroscopy were retrospectively analysed by three blinded readers for the presence and type of SLAP lesions. MR arthrograms were reviewed twice by each reader with a time interval of 4 months between the two readings. Inter- and intraobserver agreement for detection and classification of SLAP lesions were calculated using kappa coefficients. Arthroscopy confirmed 48 SLAP lesions: type I (n = 4), type II (n = 37), type III (n = 3), type IV (n = 4). Sensitivity and specificity for detecting SLAP lesions with MR arthrography for each reader were 88.6%/93.3%, 90.9%/80.0% and 86.4%/76.7%. MR arthrographic and arthroscopic grading were concurrent for 72.7%, 68.2% and 70.5% of SLAP lesions for readers 1-3, respectively. Interobserver agreement was excellent (kappa = 0.82) for detection and substantial (kappa = 0.63) for classification of SLAP lesions. For each reader intraobserver agreement was excellent for detection (kappa = 0.93, kappa = 0.97, kappa = 0.97) and classification (kappa = 0.94, kappa = 0.84, kappa = 0.93) of SLAP lesions. MR arthrography allows reliable and accurate detection of SLAP lesions. In addition, SLAP lesions can be diagnosed and classified with substantial to excellent inter- and intraobserver agreement.
    European Radiology 10/2009; 20(3):666-73. · 4.34 Impact Factor
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    ABSTRACT: Infection of a peripheral joint following arthroscopic surgery presents with an incidence of approximately 0.42% an extremely rare entity. However, septic arthritis is a serious situation possibly leading to an irreparable joint damage. Especially at delayed diagnosis patients' safety can be endangered severely. Only few precise statements regarding diagnosis and therapy have been published so far. Besides an accurate analysis of the patient's anamnesis and the assessment of the C-reactive protein especially arthrocentesis is required for diagnostic workup. For early stage infections arthroscopic therapy is proven to be of value. In addition a calculated and consecutive germ-adjusted antibiotic therapy is essential. In case of persisting signs of infection the indication for re-arthroscopy or conversion to open revision has to be stated in time. The number of necessary revisions is dependent on the initial stage of infection. For pain therapy postoperative immobilization of the affected joint is occasionally essential, if otherwise possibly early mobilization of the joint should be performed.
    Patient Safety in Surgery 04/2009; 3(1):6.
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    ABSTRACT: Current surgical procedures restoring a dislocated acromioclavicular joint aim to perform an anatomically correct and biomechanically stable reconstruction. However, the coracoidal insertions for the coracoclavicular ligaments have not yet been defined. The objective was to evaluate dimension and orientation of the coracoclavicular footprints with respect to bony landmarks for use in anatomic reconstruction of the coracoclavicular ligament complex. Descriptive laboratory study. Twenty-three (17 female, 6 male) fresh-frozen cadaveric human shoulders were dissected, and the coracoclavicular ligaments including the coracoid and the lateral clavicle were exposed. After measurement of bony coracoidal dimensions, the ligaments were dissected and the insertion sites as well as the footprint centers were identified and marked. Each coracoclavicular insertion dimension and its distance to the bony landmarks was recorded. Sex-related differences were calculated. The mean total coracoidal length was 43.1 +/- 2.2 mm. The distance from the tip of the coracoid to the precipice, the point at which the undersurface of the coracoid changes from a horizontal to a vertical direction, measured 20.3 +/- 2.6 mm. The mean distance from the conoidal center to the medial coracoidal boarder and to the precipice was 1.7 +/- 0.7 mm and 16.4 +/- 2.4 mm, respectively. The mean distance from the trapezoidal center to the medial border and to the precipice was 8.7 +/- 3 mm and 10.9 +/- 2.4 mm, respectively. The mean distance between the footprint centers was 10.1 +/- 4.2 mm. Reproducible dimensions and orientation of the coracoclavicular footprints are given. Coracoidal anatomic landmarks can be used intraoperatively for an anatomic reconstruction of the coracoclavicular ligaments.
    The American journal of sports medicine 09/2008; 36(12):2392-7. · 3.61 Impact Factor
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    ABSTRACT: Das Labrum glenoidale ist sowohl für die Funktion der Schulter als auch für ihre Stabilität von großer Bedeutung. Das Labrum glenoidale gehört zu den statischen Stabilisatoren der Schulter und trägt wesentlich dazu bei, das knöcherne Ungleichgewicht zwischen Humeruskopf und Gelenkpfanne auszugleichen. Um zwischen einem Normalbefund, einer anatomischen Variante und einem pathologischen Befund unterscheiden zu können, ist die Kenntnis der Anatomie des Labrum glenoidales grundlegend. Das periartikuläre Fasersystem, welches das Labrum glenoidale bildet, stabilisiert zum einen das Glenohumeralgelenk, zum anderen bildet es die Verbindung zwischen der Cavitas glenoidalis und der angrenzenden Kapsel, inklusive den glenohumeralen Bändern. Den Goldstandard in der Diagnostik von Verletzungen des Labrum glenoidale stellt die MRT-Untersuchung mit intraartikulärer Kontrastmittelgabe (Arthro-MRT) dar. Die unterschiedlichen Läsionen des Labrum glenoidalis bei anteroinferiorer, posteriorer und multidirektionaler Instabilität sowie bei SLAP-Läsionen werden anhand von Fallbeispielen mit Arthro-MRT Bildern und arthroskopischen Bildern veranschaulicht. The glenoid labrum is a peripherally elevated part of the glenoid rim that consists mostly of fibrous tissue. It plays an important role in the stabilization of the glenohumeral joint. The normal anatomy of the glenoid labrum varies widely and it is difficult to distinguish between normal conditions and a pathological finding. Good knowledge of the anatomy of the glenoid labrum is essential to judge clinical, radiographic and arthroscopic findings. Use of magnetic resonance arthrography (Arthro-MRI) of the shoulder is the best method to evaluate pathologic conditions of the glenoid labrum. The status of the labrum in anteroinferior, posterior and multidirectional instability of the shoulder will be shown in this article by Arthro-MRI and arthroscopic views.
    Obere Extremität 01/2007; 2(3):143-149.
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    ABSTRACT: Fragestellung Wie sind die klinischen und radiologischen Langzeitergebnisse nach autologer osteochondraler Transplantation (OATS) am Talus? Korrelieren die klinischen und radiologischen Ergebnisse miteinander? Haben Patienten mit OATS als Erst-Therapie bessere Ergebnisse als solche mit OATS nach vorhergehender andersartiger operativer Behandlung? Methodik 26 Sprunggelenke von 25 Patienten mit einem mittleren follow-up von sieben Jahren (Ø84 Monate, 53–124 Monate) nach Talus OATS wurden retrospektiv untersucht. Neun Patienten hatten anerograde und retrograde Anbohrungen als Erstversorgung mit persistierenden Beschwerden postoperativ. Prä- und postoperativ wurden der AOFAS- und Tegner Score sowie das Schmerzniveau (Visuelle Analogskala VAS) erhoben. Post-OP wurde zusätzlich die Gesamtzufriedenheit mit der Operation dokumentiert. Die Magnetresonanztomographie (MRT, T1-gewichtete Turbo Spin-Echo (TSE) (TSE) Sequenzen mit einem Driven Equilibrium (DRIVE) Impuls und eine intermediär gewichtete TSE-Sequenz mit einem spektralem Fettsupressions Impulsuls (SPIR)) wurde mit Fokus auf das Transplantat (Kongruenz, Knorpel und subchondraler Knochen), die Transplantatumgebung (Knorpel und subchondraler Knochen), Läsionen der korrespondierenden distalen Tibia sowie einen Gelenkserguss ausgewertet. Ergebnisse Der AOFAS- sowie der Tegner Score stiegen postoperativ signifikant von 50 auf 78 Punkte (p<0,01) bzw. 3,1 auf 3,7 (p<0,05) an, die VAS sank von 7,8 auf 1,5 (p<0,01). 84% der Patienten waren mit dem Ergebnis der Operation sehr zufrieden und zufrieden. Kernspintomograpisch war die Kongruenz der Transplantate in 81% normal oder zeigte minimale Unregelmäßigkeiten. Der Knorpel war in 54% unauffällig oder mit kleinen Signalveränderungen versehen. In 38% zeigten sich kleine Substanzdefekte des Transplantatknorpels. Die Patienten mit normaler Kongruenz des Transplantates oder mit minimalen Unregelmäßigkeiten hatten einen signifikant besseren AOFAS-Score (p<0,03) als die restlichen Patienten mit schlechterer Kongruenz. Im Bezug auf die anderen MRT Kategorien konnte keine Korrelation zwischen klinischen und radiologischen Ergebnissen gezeigt werden. Die neun Patienten mit vorheriger Anbohrung hatten signifikant schlechtere AOFAS- und Tegner Scores, sowie eine höhere VAS (p< 0,01, 0,08 und 0,05). Schlussfolgerung Die klinischen und radiologischen Langzeitergebnisse sieben Jahre nach osteochondraler Transplantation am Sprunggelenk sind gut und die Patienten profitieren signifikant von einem kongruent eingebrachten Transplantat. Eine Korrelation des postoperativen MRTs mit den klinischen Scores konnte im Bezug auf den Knorpel des Transplantates oder den subchondralen Knochen nicht gezeigt werden. Osteochondrale Defekte sollten initial mit einem OATS versorgt werden. MRT-Nachkontrollen nach osteochondralen Transplantationen am Sprunggelenk sind zusammenfassend nur bei Beschwerden seitens des Patienten und nicht als Routinekontrollen indiziert.
    Sport-Orthopädie - Sport-Traumatologie - Sports Orthopaedics and Traumatology. 26(2).