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Objective: The goal of the modified Ellison operation as a supplement to a conventional anterior cruciate ligament (ACL) reconstruction is to decrease anterolateral rotational instability of a knee joint after ACL rupture, to improve the stability and prevent ACL re-rupture., Indications: An ACL rupture with high risk of re-rupture (young age, high-performance sport, hyperlaxity, contralateral ACL rupture in history), increased subjective and objective anterolateral rotational instability of the knee after ACL rupture, ACL re-rupture., Contraindications: Gonarthrosis, additive instabilities (e.g. posterolateral, medial), non-anatomical ACL reconstruction with persistent instability, general contraindications to surgery (e.g. infections), chronic irritation of the knee joint., Surgical Technique: Supine position. Mark the typical landmarks. Incision from Gerdy's tubercle extending proximally along the iliotibial tract (ITT) to the lateral collateral ligament (approx. 5 cm). Incise the ITT in the line of its fibers about 10 mm anterior to its posterior border and continue the incision proximally to 5 mm proximal to the LCL. Make a parallel incision 10-12 mm anterior to the first incision. Use sharp subperiosteal dissection to elevate the strip of the ITT from Gerdy's tubercle. Secure the distal end of the ITT strip with a nonabsorbable suture (e.g. FiberWire No. 2, Arthrex, Naples, USA). Expose the LCL and pass the ITT strip deep to the LCL from proximal to distal and back to Gerdy's tubercle. Reattach the distal end of the strip of the ITT to its original position at Gerdy's tubercle with a bone anchor. The defect in the ITT can be closed with an absorbable suture (e.g. Vicryl, Ethicon, USA) in the proximal part. Layered closure., Postoperative Management: Knee brace for at least 6 weeks, movement limitation of 0‑0-90° for 6 weeks, 2 weeks 20 kg partial weight bearing., Results: A total of 36 patients (mean age 18.9 years) with a high risk of ACL re-rupture have been treated with ACL reconstruction and modified Ellison procedure. Follow-up over 2 years. Of the patients 35 returned to the previous sports level, 1 patient suffered a re-rupture, 2 patients had cyclops resection and 1 patient contralateral ACL rupture., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The clinical examination of the knee joint represents a great challenge as well as a great opportunity. In particular, ligamentous injuries are understood better despite their complexity and thus treated in a more differentiated way. A purely radiologically based diagnosis is only possible to a limited extent, especially for chronic injuries. Therefore, complex ligament injuries can be diagnosed with the aid of a differentiated clinical examination. This article gives an overview of the most important examination techniques of the knee joint, with which the decisive analysis of acute or chronic injuries and overuse syndromes of the knee can be carried out. Particularly in the field of ligament instability, this article provides a practical guide for the differentiated examination of complex rotational instability of the knee joint. In addition, the most important patellar and meniscal examination techniques are described.

Objective: Treatment of persistent anterolateral knee instability., Indications: Subjective/objective (rotational) instability of the knee after anatomic anterior cruciate ligament (ACL) reconstruction. ACL re-rupture including special demands (e.g., high-performance athletes, hyperlaxity) RELATIVE CONTRAINDICATIONS: Osteoarthritis, additional instability of the knee, which should be treated independently; non-anatomic ACL reconstruction with persisting instability should be treated first with anatomic ACL reconstruction., Absolute Contraindications: General contraindications for surgery (e. g. septic arthritis), acute irritation of the affected knee., Surgical Technique: Supine position. Incision along the proximal lateral femoral epicondyle. Marking of the needed width and length of the iliotibial band (ITB) graft. Passing the ITB graft underneath the lateral collateral ligament. Find and mark the isometric point for fixation next to the lateral femoral epicondyle. Fixation of the ITB graft. Layered wound closure., Postoperative Management: Knee brace for at least 6 weeks. Range of motion (RoM): from postoperative day 1: flexion-extension 90-0-0°; first 2 weeks after surgery: partial weight bearing (20 kg)., Results: An anterolateral extra-articular reconstruction may reduce a persistent anterolateral rotatory instability as well as the re-rupture rate following ACL reconstruction with good patient-reported short-term outcomes. Based on current (biomechanical) data, anterolateral tenodesis seems to be superior to a reconstruction of the anterolateral ligament. If a tenodesis is performed, the graft should be fixed in an isometric position, with neutral rotation of the knee and low graft tension to avoid extraphysiologic load within the lateral compartment. Indications for such a procedure may include a high-grade pivot shift or revision ACL reconstruction as well as a persistent anterolateral rotatory instability following anatomic ACL reconstruction.

Objective: Stabilization of the patella by medial patellofemoral ligament (MPFL) reconstruction., Indications: Recurrent lateral patella instability with chronic weakening of the MPFL., Contraindications: Femoropatellar cartilage defects ICRS grade 3° or higher. Tuberositas Tibiae Trochlear Groove Index (TTTG) >20 mm. Lateral hypercompression of the patella without instability., Surgical Technique: A 3 cm transverse skin incision at the superomedial edge of the patella in 90° of flexion. Longitudinal incision of the prepatellar bursa and exposure of the quadriceps tendon. Preparation of a flat tendon strip with a length of 8 cm, a width of 10 mm, and a thickness of 3 mm, leaving the attachment at the patella intact. Flipping of the tendon strip and passing of the graft through a tunnel underneath the prepatellar tissue at the medial edge of the patella. Passing of the graft in layer two of the medial joint capsule just below the fascia (layer 1) and the vastus medialis. Fixation of the graft in a bone tunnel, drilled in the femoral insertion site of the native MPFL using a biodegradable interference screw., Postoperative Management: Patella centralizing brace for 4 weeks with range of motion (ROM) 0/0/90°, 20 kg of partial weight bearing for 3 weeks. Full weight-bearing according to pain starting from week 4 postoperatively. ROM up to 90° of flexion directly postoperatively. Free ROM starting from week 6 postoperatively. Stationary cycling 6 weeks postoperatively. Swimming and running after 10 months. Return to pivoting sports after 4-5 months., Results: A total of 17 patients (7 men and 10 women; average age 21.5 years ±3.9 years, average BMI 22.6 ±3.9) were treated using this technique between March 2011 and November 2012. Only patients with at least one recurrent patella dislocation following conservative treatment were included. Patient satisfaction 12 months postoperatively was very high. Overall, 94.1 % would undergo the procedure again and 94.1 % were very satisfied with the cosmetic result. Significant improvement in Lysholm score 6, 12, and 24 months postoperatively (p < 0.05). Free ROM in 94.1 % of cases 12 months postoperatively. The Kujala score was reported to be 89 (±7.1) 12 months following surgery. No redislocation occurred during the 24 months following surgery.

Background: Reconstruction of tears in the anterior cruciate ligament with a tendon graft is the current gold standard., Objectives: Dynamic intraligamentary stabilization is a new technique for preservation of the anterior cruciate ligament., Methods: This article describes the indications, operative technique, rehabilitation and preliminary results after dynamic intraligamentary stabilization for acute anterior cruciate ligament ruptures., Results: A total of 24 women and 31 men with an acute anterior cruciate ligament tear were included in a prospective clinical trial. Of the patients 26 had already been followed-up for 12 months and satisfying values for the Lysholm, Tegner and International Knee Documentation Committee (IKDC) outcome scores were achieved. High subjective patient satisfaction was also achieved. The Lachman test showed a mean anterior translation difference to the healthy side of 1.7 mm., Conclusion: Dynamic intraligamentary stabilization in combination with microfracturing of the notch can provide biomechanical and biological conditions for self-healing of the anterior cruciate ligament. Further clinical and biomechanical research is needed to identify appropriate patients and rupture types suitable for this new technique.

Objective: The aim of arthroscopically assisted treatment of tibial plateau fractures is to achieve minimally invasive reduction and internal fixation of the joint fracture of the tibial plateau. Using the arthroscopic procedure, both the approach morbidity and the control of the articular reduction can be optimized., Indications: Displaced tibia plateau fractures of AO type A1 and B1/2/3 or Tscherne P2., Contraindications: Strongly displaced tibial plateau fractures, which require an open surgical approach and stabilization with plate fixation (e.g., AO type C fractures or Moore type 5 fractures); 2nd and 3rd degree open fractures. Danger of compartment syndrome., Surgical Technique: Planning of the surgical approach and confirmation of the indication by CT imaging. Diagnostic arthroscopy of the knee joint with treatment of associated injuries and confirming the indications for arthroscopically assisted reduction. Under arthroscopic control, insertion of an ACL tibial aiming device. In the central portion of the dislocated fracture fragment, a 2.4 mm K-wire is placed with the help of the aiming device. Opening of the outer cortex using a cannulated drill (9-11 mm diameter), introduction of a cannulated plunger below the fracture resulting in reduction of the fracture and compression of the cancellous bone below the fracture. Simultaneously the reduction is controlled by arthroscopy. Finally, the fracture is fixed using minimally invasive screw fixation (3.5-7.3 mm cancellous screws with washers) or by plate osteosynthesis (e.g., support plate). The metaphyseal defect can optionally be filled with bone substitute material., Postoperative Management: Rehabilitation is dependent on the extent of the fracture. In arthroscopically treated fractures, partial weight bearing of 20 kg over a period of 6-12 weeks is usually necessary.

Objective: Debridement and irrigation of the knee joint and the donor site to reduce the amount of bacteria and to remove bacterial enzymes and inflammatory cytokines in cases with infection after replacement of the anterior cruciate ligament (ACL)., Indications: Proven infection, suspected infection., Contraindications: High anesthesiological risk., Surgical Technique: The therapy of infections after ACL reconstruction depends on the different stages as described by Gächter. In stage I and II, arthroscopic debridement and irrigation (about 10 l) of all compartments is performed. Several biopsies for microbiological analysis are obtained during surgery. Broad-spectrum antibiotic therapy started immediately after surgery. Once the resistance of the bacteria is known, antibiotic therapy may be changed according to the results. When pain, swelling, elevated CRP, or white blood cells persists, arthroscopic irrigation is repeated. In stage III, a complete arthroscopic synovectomy is performed. When the graft is intact, it is left in situ. Resection is performed in case of graft insufficiency, tunnel malplacement, or persistent infection. When the bone tunnels are affected, they should be debrided. In stage IV with osteolysis, an arthrotomy with open debridement may be required. The surgical therapy can be supported with the application of local antibiotics., Rehabilitation: Redon drainage is left in situ until the next irrigation is performed, control of wound and laboratory results, passive exercises, physiotherapy, systemic antibiotic therapy., Results: Between 2008 and 2013, we treated 13 patients with an infection after replacement of the ACL. In all cases, complete healing was achieved. In 4 cases, the graft was resected. In 2 patients, arthrofibrosis developed and arthrolysis was required.

There is an increasing incidence of ligament ruptures of the lower extremities in older patients. This higher incidence is caused by the typical current demographic changes in the population and the higher level of activity and athletic motivation of the older people in our society. In this review we address the most important ligament ruptures of the lower extremity in the old patient. Quadriceps tendon and Achilles tendon ruptures are mostly the result of degenerative and abrasion changes. The ACL rupture on the other hand occurs spontaneously after adequate trauma and without former degenerative changes especially in highly active patients. For a differentiated treatment of the older patient with tendon ruptures, secondary diseases, an increased risk and complication profile and a potentially decreased compliance during rehabilitation must be taken into consideration before indicating operative or conservative therapy. There are no strict age-related limitations for indication of an operative treatment of tendon ruptures in the older patient. In this patient group a differentiated treatment decision is recommended.

Background: It is hypothesized that misplacement of sustentacular screws during osteosynthesis of intraarticular calcaneal fractures can be reduced with the help of navigation. A method for three-dimensional (3D) navigated placement of sustentacular screws for treating intraarticular calcaneal fractures is presented and evaluated., Material and Methods: 11 consecutive patients with 15 intraarticular calcaneal fractures were treated using 3D navigation. In 12 cases osteosynthesis was done through an extended lateral approach; in three cases, it was achieved through a minimally invasive percutaneous approach. For verification and documentation of the placed screws, a second 3D scan was performed., Results: A total of 20 screws were placed using 3D navigation. None of the navigated screws was misplaced. Extra operating time due to navigation averaged 11.9 minutes (+/-2.2 min)., Conclusion: Through a combination of intraoperative 3D imaging and navigation, placement of sustentacular screws is possible and can yield precise and reliable results. Especially in minimally invasive treatment, a high quality of osteosynthesis can be achieved.