Search

Background: Recent evidence questions the role of medial opening wedge high tibial osteotomy (mowHTO) in the correction of femoral-based varus malalignment because of the potential creation of an oblique knee joint line. However, the clinical effectiveness of alternatively performing an isolated lateral closing wedge distal femoral osteotomy (lcwDFO), in which the mechanical unloading effect in knee flexion may be limited, is yet to be confirmed. Purpose/Hypothesis: The purpose of this article was to compare clinical outcomes between patients undergoing varus correction via isolated lcwDFO or mowHTO, performed according to the location of the deformity, in a cohort matched for confounding variables. It was hypothesized that results from undergoing isolated lcwDFO for symptomatic varus malalignment would not significantly differ from the results after mowHTO. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent isolated mowHTO or lcwDFO according to a tibial- or femoral-based symptomatic varus deformity between January 2010 and October 2019 were enrolled. Confounding factors, including age at surgery, sex, body mass index, preoperative femorotibial axis, and postoperative follow-up, were matched using propensity score matching. The International Knee Documentation Committee (IKDC) Subjective Knee Form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively. Results: Of 535 knees assessed for eligibility, 50 knees (n = 50 patients, n = 25 per group) were selected by propensity score matching. Compared with preoperatively, both the mowHTO group (IKDC, 55.1 ± 16.5 vs 71.3 ± 14.7, P = .002; WOMAC, 22.0 ± 18.0 vs 9.6 ± 10.8, P < .001; Lysholm, 55.2 ± 23.1 vs 80.7 ± 16, P < .001; VAS, 4.1 ± 2.4 vs 1.6 ± 1.8, P < .001) and the lcwDFO group (IKDC, 49.4 ± 14.6 vs 66 ± 20.1, P = .003; WOMAC, 25.2 ± 17.0 vs 12.9 ± 17.6, P = .003; Lysholm, 46.5 ± 15.6 vs 65.4 ± 28.7, P = .011; VAS, 4.5 ± 2.2 vs 2.6 ± 2.5, P = .001) had significantly improved at follow-up (80 ± 20 vs 81 ± 43 months). There were no significant differences between the groups at baseline, at final follow-up, or in the amount of clinical improvement in any of the outcome parameters ( P > .05; respectively). Conclusion: Performing both mowHTO or lcwDFO yields significant improvement in clinical outcomes if performed at the location of the deformity of varus malalignment. These findings confirm the clinical effectiveness of performing an isolated lcwDFO in femoral-based varus malalignment, which is comparable with that of mowHTO in the correction of varus malalignment.

To evaluate return to sport (RTS) and work (RTW), as well as clinical outcomes following double level osteotomy (DLO) via combined medial open wedge high tibial osteotomy and lateral closing wedge distal femoral osteotomy for bifocal symptomatic varus malalignment, and to compare these outcome parameters between patients undergoing a single surgery and those undergoing a two-stage procedure.Consecutive patients who underwent DLO for symptomatic varus malalignment between 12/2007 and 03/2018 were enrolled. Patients converted to arthroplasty (n = 3) during follow-up were excluded. Outcome measures included the International Knee Documentation Committee (IKDC) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain, which were collected preoperatively and at a minimum of 24 months postoperatively. RTS and RTW were evaluated by questionnaire. Outcome measures were compared between DLO performed in a single- versus a two-stage surgery.Thirty-two patients (mean age: 44.2 ± 12.6 years), who underwent DLO for varus malalignment (10.1° ± 2.9°) were included at a mean follow-up of 56.9 ± 35.3 months (range: 24-148). Compared to preoperatively, these patients significantly improved in IKDC (50.4 ± 13.9 to 66.1 ± 15.4; P.001), WOMAC (29.7 ± 19.2 to 11.8 ± 13.5; P.001) and Lysholm (53.6 ± 23.6 to 73.1 ± 23.6; P = .002) scores at final follow-up. For the WOMAC score, 78% of the patients included reached the minimally important clinical difference, along with a significant reduction of the VAS for pain (5.0 ± 3.0 to 2.5 ± 2.4; P.001). Postoperatively, 96% of patients returned to sport after 7.7 ± 4.8 months, but at a lower frequency (P = .010) and to fewer disciplines (P = .005) with a shift to low-impact sports. 90% of the patients returned to work at a mean 5.9 ± 9.4 months, with 79% reporting a similar or superior working ability. Patients undergoing a two-stage procedure recovered to full physical working ability at a significantly longer duration, as compared to a single-stage procedure (9.8 ± 3.8 vs 9.0 ± 13.1 months; P = .047).The majority of patients undergoing DLO for symptomatic varus malalignment, who were not converted to arthroplasty, experienced clinically significant functional improvement at mid-term follow-up. Return to sport and work rates in these patients were high; however, a shift to lower-impact sports disciplines was observed. Similar clinical outcomes can be expected when performing DLO in a single surgery or a two-stage procedure.Retrospective case series; Level IV.

Purpose The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev). Methods The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1–3 was considered ‘inappropriate’, 4–6 ‘uncertain’, and 7–9 ‘appropriate’). Results The criteria used to define the scenarios were: age (18–35 years vs 36–50 years vs 51–60 years), sports activity and expectation (Tegner 0–3 vs 4–6 vs 7–10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren–Lawrence [KL] grade 0–I–II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51–60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III). Conclusion This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications. Level of evidence II.

Zusammenfassung Hintergrund Die patellofemorale Instabilität zählt zu den häufigsten Pathologien des Kniegelenks. Die Planung und Durchführung patellastabilisierender Operationen ist sehr variabel. Bezüglich der operativen Maßnahmen kommt der präoperativen Planung, gerade im Hinblick auf die häufig hohe Komplexität der zugrundeliegenden Pathologien, eine entscheidende Bedeutung zu. Fragestellung Ziel dieser Studie war es, die aktuelle Versorgungsrealität in Bezug auf Planung und Durchführung patellastabilisierender Operationen unter Mitgliedern der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) abzubilden. Des Weiteren sollte erhoben werden, ob ggf. automatisierte Analysen der zugrundeliegenden Anatomie die Planung und Durchführung patellastabilisierender Operationen (im Primär- und Revisionsfall) beeinflussen würden. Material und Methoden Unter allen aktiven Mitgliedern der DGOU wurde per Mail eine anonymisierte Online-Umfrage mit 16 Fragen erhoben. 7974 Mitglieder wurden angeschrieben, 393 Rückmeldungen konnten anschließend analysiert werden. Ergebnisse Die MPFL-Plastik (89,8 %) ist die am häufigsten durchgeführte Operation zur Patellastabilisierung. Dahinter folgen Tuberositasversatzoperationen (64,9 %), Korrekturosteotomien (51,2 %) und Trochleaplastiken (19,9 %). Die Wahl bezüglich des operativen Vorgehens fällt überwiegend auf Grundlage einer Kombination aus klinischen und radiologischen Befunden (90,3 %). Für die Entscheidung zur Operation werden hauptsächlich MRT-Bildgebung (81,2 %), Standard-Röntgenbilder (77,4 %) und Beinganzaufnahmen (76,6 %) herangezogen. Insgesamt würden 59,3 % der Befragten eine automatisierte Analyse für eine vereinfachte präoperative Planung und die Detektion von entscheidenden radiologischen Parametern (59,0 %) in Anspruch nehmen, sofern diese zur Verfügung stünden. Diskussion Die Erhebungen dieser Umfrage unter Mitgliedern der DGOU weisen die MPFL-Plastik als zentralen Ansatzpunkt zur operativen Behandlung patellofemoraler Instabilitäten aus, diagnostisch ist die MRT-Bildgebung essenziell. Durch eine zukünftige Etablierung automatisierter Software-gestützter Analysemethoden könnte bei einer Vielzahl von Operateuren eine Erweiterung der radiologisch berücksichtigten Parameter in der Planung patellastabilisierender Operationen erreicht werden.

Purpose To evaluate immediate loss of reduction in patients undergoing hardware removal after arthroscopically assisted acromioclavicular (AC) joint stabilization using a high-tensile suture tape suspensory fixation system and to identify risk factors associated with immediate loss of reduction. Materials and methods Twenty-two consecutive patients with a mean age of 36.4 ± 12.6 years (19–56), who underwent hardware removal 18.2 ± 15.0 months following arthroscopically assisted stabilization surgery using a suspensory fixation system for AC joint injury between 01/2012 and 01/2021 were enrolled in this retrospective monocentric study. The coracoclavicular distance (CCD) as well as the clavicular dislocation/acromial thickness (D/A) ratio were measured on anterior–posterior radiographs prior to hardware removal and immediately postoperatively by two independent raters. Loss of reduction, defined as 10% increase in the CCD, was deemed substantial if the CCD increased 6 mm compared to preoperatively. Constitutional and surgical characteristics were assessed in a subgroup analysis to detect risk factors associated with loss of reduction. Results Postoperatively, the CCD significantly increased from 12.6 ± 3.7 mm (4.8–19.0) to 14.5 ± 3.3 mm (8.7–20.6 mm) (p p = 0.034) compared to preoperatively. In 10 cases (45%), loss of reduction was identified, while a substantial loss of reduction (> 6 mm) was only observed in one patient (4.5%). A shorter time interval between index stabilization surgery and hardware removal significantly corresponded to immediate loss of reduction (11.0 ± 5.6 vs. 30.0 ± 20.8 months; p = 0.007), as hardware removal within one year following index stabilization was significantly associated with immediate loss of reduction (p = 0.027; relative risk 3.4; odds ratio 11.67). Conclusions Substantial loss of reduction after hardware removal of a high-tensile suture tape suspensory fixation system was rare, indicating that the postoperative result of AC stabilization is not categorically at risk when performing this procedure. Even though radiological assessment of the patients showed a statistically significant immediate superior clavicular displacement after this rarely required procedure, with an increased incidence in the first year following stabilization, this may not negatively influence the results of ACJ stabilization in a clinically relevant way. Level of evidence IV.

Purpose Posterior lateral meniscus root (PLMR) tears are injuries that commonly occur together with anterior cruciate ligament (ACL) tears. The aim of this study was to evaluate the clinical and radiological outcome of PLMR repair accompanying ACL reconstruction. Specifically, PLMR healing rates, meniscal extrusion behavior and their influence on patient-reported outcome measures (PROMs) were analyzed. It was hypothesized that PLMR repair shows satisfactory healing rates and coronal meniscal extrusion does not increase significantly following PLMR repair. Methods Patients that underwent PLMR repair between 2014 and 2019 were evaluated at least 12 months postoperatively. At follow-up, magnetic resonance imaging (MRI) was performed in order to evaluate the PLMR healing behavior (complete vs. partial vs. no healing) as well as the coronal and sagittal meniscal extrusion in comparison with the preoperative MRI. Additionally, patient-reported outcome measures (PROMs; Lysholm score, International Knee Documentation Committee subjective knee form [IKDC]) were compiled. Pre- and postoperative meniscal extrusion were tested for statistical significance using the paired t test. The Kruskal–Wallis test was used to compare extrusion values and PROMs in relation to different healing states. A correlation analysis was conducted using the Pearson correlation coefficient between differences in meniscal extrusion and PROMs. Results Out of 25 patients, 18 patients (72.0%; 11 male and seven female) were available for final assessment at a mean follow-up of 40.8 ± SD 17.5 months. One revision PLMR repair was performed five months after the initial repair. In 14 cases (77.8%), healing of the lateral meniscus was observed (6 × complete, 8 × partial). Coronal extrusion of the lateral meniscus did not increase significantly following PLMR repair (2.0 ± 1.5 mm vs. 2.1 ± 1.3 mm; p = 0.645). Sagittal extrusion increased significantly (25.7 ± 2.4 mm vs. 27.0 ± 1.4 mm; p p > 0.05). But a higher increase in coronal meniscal extrusion negatively affected PROMs (Lysholm score: p = 0.046, r = − 0.475; IKDC: p = 0.003, r = − 0.651). Conclusion High healing rates of the PLMR and no significant increase in coronal extrusion may be expected following combined PLMR repair and ACL reconstruction. But a greater increase in postoperative coronal meniscal extrusion correlates with less favorable clinical results. A greater increase in sagittal extrusion was observed, but this did not influence the clinical outcome. Level of evidence Retrospective Case Series; IV.

Purpose Focal, patellar cartilage defects are a challenging problem as most cases have an underlying multifactorial pathogenesis. This systematic review of current literature analysed clinical results after regenerative cartilage repair of the patella with a special focus on the assessment and treatment of existing patellofemoral malalignment. Methods A systematic review was conducted to identify articles reporting clinical results after cartilage regenerative surgeries of the patella using the PubMed and Scopus database. The extracted data included patient-reported outcome measures (PROMS) and whether cartilage repair was performed alone or in combination with concomitant surgeries of underlying patellofemoral co-pathologies. In cases of isolated cartilage repair, specific exclusion criteria regarding underlying co-pathologies were screened. In cases of concomitant surgeries, the type of surgeries and their specific indications were extracted. Results A total of 35 original articles were included out of which 27 (77%) were cohort studies with level IV evidence. The most frequently used technique for cartilage restoration of the patella was autologous chondrocyte implantation (ACI). Results after isolated cartilage repair alone were reported by 15 (43%) studies. Of those studies, 9 (60%) excluded patients with underlying patellofemoral malalignment a priori and 6 (40%) did not analyse underlying co-pathologies at all. Among the studies including combined surgeries, the most frequently reported concomitant procedures were release of the lateral retinaculum, reconstruction of the medial patellofemoral ligament (MPFL), and osteotomy of the tibial tubercle. In summary, these studies showed lower preoperative PROMS but similar final PROMS in comparison with the studies reporting on isolated cartilage repair. The most frequently used PROMS were the IKDC-, Lysholm- and the Modified Cincinnati Score. Conclusion This comprehensive literature review demonstrated good clinical outcomes after patellar cartilage repair with no evidence of minor results even in complex cases with the need for additional patellofemoral realignment procedures. However, a meaningful statistical comparison between isolated patellar cartilage repair and combined co-procedures is not possible due to very heterogeneous patient cohorts and a lack of analysis of specific subgroups in recent literature. Level of evidence Level IV.

The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision.The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document.The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below.ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance.II.

Im klinischen Alltag angewandte chirurgische Knorpeltherapieverfahren sind fur fokale Knorpelschaden etabliert, allerdings sind in der Versorgungsrealitat degenerative Knorpelschaden mit Affektion weiterer Kniebinnenstrukturen wesentlich haufiger. Dieses Stadium, in welchem klassische radiologische Arthrosezeichen fehlen, wird als Fruharthrose bezeichnet und ist gekennzeichnet durch eine gestorte Gelenkhomoostase mit biomechanischen und biochemischen Veranderungen, welche sich negativ auf regenerative Knorpeltherapieverfahren auswirken konnen. Die Indikation zur chirurgischen Knorpeltherapie besteht bei der symptomatischen fokalen Fruharthrose, welche nach Madry et al. definiert ist als Knorpeldegeneration ICRS(International Cartilage Repair Society)-Grad I oder II welche um einen fokalen Knorpelschaden ICRS-Grad III oder IV lokalisiert ist. Bei fortgeschrittener Arthrose mit deutlicher Gelenkspaltverschmalerung sind samtliche chirurgischen Knorpeltherapieverfahren im Allgemeinen nur in Ausnahmefallen indiziert. Das am besten untersuchte Verfahren bei der Fruharthrose ist die autologe Chondrozytentransplantation, welche in Fallserien akzeptable Ergebnisse erzielte, allerdings muss mit hoheren Versagensraten als bei fokalen, traumatischen Knorpelschaden gerechnet werden. Der Nutzen von knochenmarkstimulierenden Techniken scheint bei der Fruharthose limitiert zu sein und sollte lediglich bei kleinem Schaden

Knorpelschaden des Patellofemoralgelenks fuhren haufig zu erheblichen Beschwerden und funktionellen Beeintrachtigungen der Betroffenen. Mit der Zeit entstehen aufgrund einer atypischen Kinematik degenerative Veranderungen, die mittel und langfristig in der Ausbildung einer patellofemoralen Arthrose munden. In den letzten Jahren konnten mehrere Studien zeigen, dass eine erfolgreiche Knorpeltherapie erreicht werden kann, wenn die begleitenden oder besser gesagt die zugrunde liegenden Pathologien mitbehandelt werden. Die Ergebnisse konnen so durchaus auch gleich gut oder sogar besser sein als im tibiofemoralen Kompartiment. Besondere Bedeutung bei der Entstehung chondraler oder osteochondraler Lasionen hat die akute Patellainstabilitat. Aber auch direkte Anpralltraumata kommen vor. Diese akuten Verletzungen von Knorpel und Knochen sollten ebenfalls zeitnah versorgt werden. Chronische Patellainstabilitaten fuhren in der Regel zu chronischem Verschleis des Knorpels. Diese entstehen zumeist auf dem Boden einer gestorten Kinematik. Aus dieser entstehen dann Scherbelastung oder Fehlbelastung. In beiden Fallen sollten in der Therapie die Begleitpathologien erkannt und mittherapiert werden, um die Entwicklung einer Arthrose abzuwenden. Die Behandlung der Knorpelschaden ist in den vergangenen Jahren um das sog. „Minced-cartilage“-Verfahren, welches bei rein knorpeligen Schaden zum Einsatz kommen sollte, erweitert worden. Aber auch die guten Ergebnisse der Knorpelzelltransplantation an der Patella oder Trochlea waren ermutigend. Die Anwendung der autologen matrixinduzierten Chondrogenese ist in der Anwendung noch nicht gut definiert, hat aber sicher ihren Platz zwischen der Mikrofrakturierung ( 2,5–3 cm2), also bei 1–4 cm2.

Die Menisken stellen einen integralen Bestandteil des Kniegelenks dar. Wurzel- und Rampenlasionen sind in den letzten Jahren zunehmend in den Fokus geraten. Wurzelverletzungen sind biomechanisch mit einer totalen Meniskektomie gleichzusetzen, erhohen die Belastung auf den Gelenkknorpel und tragen zu Kniegelenkinstabilitaten bei. Rampenlasionen treten im Zuge von Verletzungen des vorderen Kreuzbands (VKB) auf, werden haufig ubersehen und konnen durch ihre kinematischen Auswirkungen das Risiko einer VKB-Reruptur erhohen. Fur beide Verletzungsentitaten sind eine strukturierte diagnostische Abklarung und ein individuell angepasstes Therapieregime unabdingbar. In diesem Artikel wird die aktuelle Evidenzlage diskutiert und Behandlungsempfehlungen fur Wurzel- und Rampenlasionen gegeben.

Purpose To evaluate the clinical outcomes of patients with a minimum 2-year follow-up following contemporary patellofemoral inlay arthroplasty (PFIA) and to identify potential risk factors for failure in a multi-center study. Methods All patients who underwent implantation of PFIA between 09/2009 and 11/2016 at 11 specialized orthopedic referral centers were enrolled in the study and were evaluated retrospectively at a minimum 2-year follow-up. Clinical outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Tegner Scale, the visual analogue scale (VAS) for pain, and subjective patient satisfaction. Pre- and perioperative risk factors were compared among failures and non-failures to determine potential risk factors. Results A total of 263 patients (85% follow-up rate) could be enrolled. The mean age at the time of index surgery was 49 ± 12 years with a mean postoperative follow-up of 45 ± 18 months. The overall failure rate was 11% (28 patients), of which 18% (5 patients) were patients with patella resurfacing at index surgery and 82% (23 patients) were patients without initial patella resurfacing. At final follow-up, 93% of the patients who did not fail were satisfied with the procedure with a mean transformed WOMAC Score of 84.5 ± 14.5 points, a mean KOOS Score of 73.3 ± 17.1 points, a mean Tegner Score of 3.4 ± 1.4 points and a mean VAS pain of 2.4 ± 2.0 points. An increased BMI was significantly correlated with a worse postoperative outcome. Concomitant procedures addressing patellofemoral instability or malalignment, the lack of patellofemoral resurfacing at the index surgery and a high BMI were significantly correlated with failure in our patient cohort. Conclusion Patellofemoral inlay arthroplasty shows high patient satisfaction with good functional outcomes at short-term follow-up and thus can be considered a viable treatment option in young patients suffering from isolated patellofemoral arthritis. Patellar resurfacing at index surgery is recommended to decrease the risk of failure. Level of evidence Retrospective case series, Level IV.

Purpose To evaluate the incidence, morphology, and associated complications of medial cortical hinge fractures after lateral closing wedge distal femoral osteotomy (LCW-DFO) for varus malalignment and to identify constitutional and technical factors predisposing for hinge fracture and consecutive complications. Methods Seventy-nine consecutive patients with a mean age of 47 ± 12 years who underwent LCW-DFO for symptomatic varus malalignment at the authors’ institution between 01/2007 and 03/2018 with a minimum of 2-year postoperative time interval were enrolled in this retrospective observational study. Demographic and surgical data were collected. Measurements evaluating the osteotomy cut (length, wedge height, hinge angle) and the location of the hinge (craniocaudal and mediolateral orientation, relation to the adductor tubercle) were conducted on postoperative anterior–posterior knee radiographs and the incidence and morphology of medial cortical hinge fractures was assessed. A risk factor analysis of constitutional and technical factors predisposing for the incidence of a medial cortical hinge fracture and consecutive complications was conducted. Results The incidence of medial cortical hinge fractures was 48%. The most frequent morphological type was an extension fracture type (68%), followed by a proximal (21%) and distal fracture type (11%). An increased length of the osteotomy in mm (53.1 ± 10.9 vs. 57.7 ± 9.6; p = 0.049), an increased height of the excised wedge in mm (6.5 ± 1.9 vs. 7.9 ± 3; p = 0.040) as well as a hinge location in the medial sector of an established sector grid (p = 0.049) were shown to significantly predispose for the incidence of a medial cortical hinge fracture. The incidence of malunion after hinge fracture (14%) was significantly increased after mediolateral dislocation of the medial cortical bone > 2 mm (p Conclusion Medial cortical hinge fractures after LCW-DFO are a common finding. An increased risk of sustaining a hinge fracture has to be expected with increasing osteotomy wedge height and a hinge position close to the medial cortex. Furthermore, dislocation of a medial hinge fracture > 2 mm was associated with malunion and should, therefore, be avoided. Level of evidence Prognostic study; Level IV.

PurposeTo compare post-operative physical activity and return to work after combined posterolateral corner (PLC) reconstruction (PLC-R) in anterior cruciate ligament (ACL)- or posterior cruciate ligament (PCL)-based injuries.MethodsPatients aged > 18 years undergoing PLC-R using the Larson technique combined with either ACL or PCL reconstruction were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using Tegner Activity Scale, Activity Rating Scale (ARS), Knee Injury and Osteoarthritis Outcome Score (KOOS), work intensity according to REFA classification, and a questionnaire about type of occupation and time to return to work.ResultsA total of 32 patients (11 ACL-based injuries and 21 PCL-based injuries) were included. Mean follow-up was 56 ± 26 months in the ACL-based injury group and 59 ± 24 months in the PCL-based injury group. All patients in the ACL-based injury group and 91% of patients in the PCL-based injury group returned to sports activities. Comparing pre- and post-operative values, a significant deterioration of the Tegner Activity Scale and ARS was observed in the PCL-based injury group, whereas no significant change was observed in the ACL-based injury group. KOOS subscales were generally higher in the ACL-based injury with significant differences in the subscale sports and recreational activities. Patients with ACL-based injuries returned to work significantly earlier compared to patients with PCL-based injuries (11 ± 4 weeks vs. 21 ± 10 weeks,p ConclusionHigh rates of return to sports and work can be expected after combined PLC-R in both ACL- and PCL-based injuries. However, deterioration of sports ability must be expected in PCL-based injuries. ACL-based injuries led to superior patient-reported outcomes and an earlier return to work, as compared to PCL-based injuries.Level of evidenceLevel IV.

Die isolierte Arthrose des Patellofemoralgelenkes stellt eine seltene und komplexe Erkrankung dar. Nach Ausschopfen der konservativen Therapie stehen dem Orthopaden diverse weichteilige und knocherne rekonstruktive Verfahren sowie knorpelregenerative Verfahren zur Verfugung. Bei fehlgeschlagener oder unbefriedigender Therapie wird die Patellofemoralprothese als Therapiealternative weiterhin kontrovers diskutiert. Bei genauerer Betrachtung der Studien zeigen sich vielversprechende Ergebnisse bei korrekter Indikationsstellung und Patientenselektion. Die unterschiedlichen Prothesendesigns liefern gute postoperative Ergebnisse bei Beachtung von generellen und spezifischen Risiken. Die aktuelle Generation der patellofemoralen Inlay-Prothesen zeigt eine hohe Patientenzufriedenheit mit signifikanten Verbesserungen der Kniefunktion und Schmerzlinderung in mittelfristen Ergebnissen, bei allerdings nicht unerheblicher Revisionsrate.

PurposeTo analyze postoperative physical and sexual activity as well as Quality of Life (QoL) after complex patellofemoral reconstructions in female patients suffering from chronic patellofemoral instability (PFI).MethodsFemale patients aged > 18 years undergoing complex patellofemoral reconstruction for chronic PFI were included. Complex patellofemoral reconstruction was defined as medial patellofemoral ligament reconstruction (MPFL-R) combined with at least one major bony procedure (distal femoral osteotomy, high tibial osteotomy, and trochleoplasty). Outcome was evaluated retrospectively after a minimum follow-up of 12 months using Tegner activity scale, Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0), EuroQol-5D-3L (EQ-5D-3L), EuroQol Visual analog scale (EQ-VAS), and a questionnaire about sexual activity.ResultsA total of 34 females (mean age, 26 ± 5 years) with a mean follow-up of 45 ± 16 months were included. Seventy-seven percent had one major bony correction + MPFL-R and 24% had at least two major bony corrections + MPFL-R. The re-dislocation rate was 6%. Median Tegner activity scale improved from 3 (range 0–10) to 4 (range 2–6) (n.s.) and an improved activity level was observed in 49% of subjects. QoL scores showed an EQ-5D-3L Index Value of 0.89 ± 0.15, EQ-VAS of 80.3 ± 11.4, and BPII of 68.3 ± 19.1. Thirty-four percent of patients reported restrictions of sexual activities due to PFI preoperatively with an improved sexual function observed in 60% postoperatively due to less pain, improved mobility, and less apprehension. Postoperative return to sexual activity was 91%, whereof 19% reported current restrictions of sexual function because of pain and/or limited range of motion.ConclusionDespite the complexity and invasiveness of complex patellofemoral reconstruction, combined bony procedures and MPFL-R resulted in a low redislocation rate, improved physical activity and QoL comparable to values reported after isolated MPFL-R. Furthermore, sexual activity was improved in 60% of females with preoperative restrictions.Level of evidenceIV.

Veroffentlichungen uber die Bedeutung des „posterior tibial slope“, die Neigung des Tibiaplateaus nach dorsal, nehmen in den letzten Jahren stetig zu. Primar trat dieses Thema als „Nebeneffekt“ der valgisierenden hohen tibialen Osteotomie (HTO) in den Fokus, als erkannt wurde, dass die Eingriffe in der Frontalebene mit Veranderungen in der Sagittalen einhergehen. Die Neigung des Tibiaplateaus kann im seitlichen Rontgen und in sagittalen MRT-Schichten gemessen werden. Es besteht jedoch bislang keine Einigkeit daruber, welche Messtechnik anzuwenden ist, und wann ein Neigungswinkel als steil bzw. zu steil bewertet werden muss. Gemas der Darstellung im seitlichen Rontgen wurde in ersten Studien an den Knochenkonturen des medialen und lateralen Plateaus gezeigt: Ein steiler tibialer Slope fuhrt zu vermehrter anteriorer tibialer Translation (ATT); diese Zusammenhange gibt es sowohl im kreuzbandinsuffizienten als auch im kreuzbandintakten Knie. Selbstverstandlich ist nicht der Knochen die eigentliche oder einzige formgebende Struktur: Die Gelenkoberflache wird vom Knorpel und von den Menisken gebildet. Folglich wird in immer mehr Studien auch der sog. weichteilige Slope bestimmt. Bei Patienten mit einer Ruptur des vorderen Kreuzbands (VKB) zeigt sich nicht nur der knocherne, sondern auch der weichteilige mediale und laterale Slope signifikant steiler als bei den gesunden Vergleichspersonen. Die v. a. durch den steilen lateralen Slope beim „Knee-in-and-toe-out“-Mechanismus vermittelte ATT zeichnet sich wahrscheinlich fur mehr als 50 % aller VKB-Rupturen verantwortlich. Oft ist dieser Mechanismus mit einer abrupten intensiven Quadrizepsaktivierung und reduzierter „Hamstring“-Koaktivierung kombiniert. Die Rolle der Hamstrings in Abhangigkeit vom tibialen Slope wird jedoch noch kontrovers diskutiert.

Purpose Ultrasound (US) examination of the medial joint space of the knee has played a subordinate diagnostic role up till now. The purpose of the present study was to describe mean values of medial joint width and to investigate the impact of gender, age, and body mass index (BMI) on medial joint laxity in healthy knees using modern, dynamic US in a standardized fashion in unloaded and standardized loaded conditions. Methods A total of 65 subjects with 79 healthy knees were enrolled in this study. All volunteers underwent clinical examination of the knee. The medial knee joint width was determined using US in a supine position at 0° and 30° of knee flexion in unloaded and standardized loaded (= 15 Dekanewton, daN) conditions using a specific device. Mean values were described and correlations between medial knee joint width and gender, age, and BMI were assessed. Results Thirty-two females and 33 males were enrolled in this study. The mean medial joint width in 0° unloaded was 5.7 ± 1.2 mm and 7.4 ± 1.4 mm loaded. In 30° of knee flexion, the mean medial joint width was 6.1 ± 1.1 mm unloaded and 7.8 ± 1.2 mm loaded. The average change between unloaded and loaded conditions in 0° was 1.7 ± 1.0 mm and in 30° 1.7 ± 0.9 mm. A significant difference between genders was evident for medial joint width in 0° and 30° of flexion in unloaded and loaded conditions (p p = 0.032). No significant correlation between BMI and medial joint width in US could be found. Conclusion Mean values of medial joint width in unloaded and standardized loaded conditions using a fixation device could be demonstrated. Based on the results of this study, medial knee joint width in US is gender- and age-related in healthy knees. These present data may be useful for evaluating patients with acute or chronic pathologies to the medial side of the knee. Level of evidence III.

Purpose The aim of this study was, to investigate the rate of return to sports (RTS) and physical activity after implantation of PFIA and to identify factors predictive of improved postoperative sporting ability. Methods Sixty-two patients with a mean age of 46 ± 11 years, who underwent implantation of PFIA at the senior authors’ institution, were enrolled. They were prospectively evaluated preoperatively and at a minimum of 2 years postoperatively with a mean follow-up of 60 ± 25 months. Clinical outcomes, return to sports and activity, type of sport or activity, subjective satisfaction, and frequency were evaluated by questionnaire. Results The transformed overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 67 ± 16 to 77 ± 19 (p = 0.003), Tegner activity scale results improved from 3 ± 2 points to 4 ± 1 points (p p p = 0.001). Ninety-four percent of the patients who did not fail could return to the same or higher level of sports, with 74% of the patients reporting an improved ability to perform sports. No preoperative factors could be detected to significantly influence RTS after surgery. Conclusions PFIA is a valid treatment option for the active patient with end-stage isolated patellofemoral OA. Reliable improvements in knee function, pain, and participation in low-impact sports were found. Level of evidence IV.

Purpose To evaluate the incidence and morphology of medial cortical hinge fractures in lateral open wedge distal femoral osteotomy (LOW-DFO) and to determine a safe zone for the position of the osteotomy hinge to minimize the risk of hinge fractures. Methods Consecutive patients who underwent LOW-DFO for symptomatic valgus malalignment were screened for eligibility for this retrospective observational cohort study. Demographical and surgical data were collected. The incidence and morphology of medial cortical hinge fractures were evaluated on standard postoperative anterior–posterior knee radiographs. Comprehensive measurements evaluating the osteotomy gap and the position of the osteotomy hinge were taken. Additionally, each osteotomy hinge was assigned to a corresponding sector of a proposed five-sector grid of the distal medial femur. Results A total of 100 patients (60% female) with a mean age of 31 ± 13 years were included. The overall incidence of medial cortical hinge fractures was 46% and three distinct fracture types were identified. The most frequently observed fracture type was extension of the osteotomy gap (76%), followed by a proximal (20%) and distal (4%) course of the fracture line in relation to the hinge. Group comparison (hinge fracture vs. no hinge fracture) showed statistically significant higher values for the height of the osteotomy gap (p = 0.001), the wedge angle (p = 0.036), and the vertical distance between the hinge and the proximal margin of the adductor tubercle (AT; p = 0.002) in the hinge fracture group. Furthermore, a significantly lower horizontal distance between the hinge and the medial cortical bone (p = 0.036) was observed in the hinge fracture group. A statistically significant higher incidence of medial cortical hinge fractures was observed when the position of the osteotomy hinge was proximal compared to distal to the proximal margin of the AT (53% vs. 27%; p = 0.023). Conclusion Medial cortical hinge fractures in LOW-DFO are a common finding with three distinct fracture types. To minimize the risk of medial cortical hinge fractures, it is recommended to aim for a position of the osteotomy hinge at the level of or distal to the proximal margin of the adductor tubercle. Level of evidence Prognostic study; Level III

Kombinierte Verletzungen des vorderen Kreuzbandes (VKB) und des medialen Kapselbandapparates sind haufig und fuhren zu einer veranderten Kinematik des Kniegelenks. Zur Behandlung stehen grundsatzlich konservative und operative Verfahren zur Auswahl, welche aber auch kombiniert zur Anwendung kommen konnen. Symptomatische, chronische mediale Kniegelenksinstabilitaten werden operativ behandelt. Dabei stehen verschiedene Rekonstruktionstechniken zur Verfugung. Die Behandlung dieser Verletzungen setzt eine Kenntnis der komplexen anatomischen und biomechanischen Zusammenhange voraus. Dieser Artikel soll helfen, im Fall einer vorderen und medialen Knieinstabilitat zufriedenstellende Behandlungsergebnisse zu erzielen und bietet eine Darstellung der derzeit gangigen operativen Methoden.

To determine the prevalence of a deep lateral femoral notch sign (LFNS) in magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus (PLRT). A retrospective chart review was conducted to identify all patients undergoing ACL reconstruction between 2016 and 2018. Based on the arthroscopic appearance of the lateral meniscus, patients were assorted to one of three groups: isolated ACL tear (ACL-Group), ACL tear with concomitant lateral meniscus tear not involving the posterolateral root (Meniscus-Group), and ACL tear with concomitant PLRT (PLRT-Group). Incidence and depth of a LFNS on preoperative MRI was compared between the three cohorts. 115 patients (mean age: 29.5 ± 11.3 years) were included in the study, with 58 patients (50.4%) assorted to the ACL-Group, 24 patients (20.9%) to the Meniscus-Group, and 33 patients (28.7%) to the PLRT-Group. The prevalence of a LFNS was significantly higher in the PLRT-Group (39.4%), when compared to the ACL- (5.2%) or Meniscus-Groups (25.0%; p

To biomechanically investigate the influence of osseous valgus alignment, with and without deficiency of the posteromedial ligament complex (PMC), on ACL-graft forces under axial load. ACL reconstruction was performed on ten cadaveric knee joints. A lateral distal femur osteotomy was then done to adjust for three different alignment conditions according to the position, where the axial weight bearing line (WBL) dissected the tibial plateau (% from medial to lateral): 50%, 85% and 115%. Each alignment was tested with the PMC intact, deficient and reconstructed. Axial loads of 400 N were applied in 15° of knee flexion and changes of ACL-graft forces and dynamic valgus angle (DVA) were recorded. In the PMC intact state, lateralization of the WBL to 85% and to 115% led to significantly increased ACL graft forces (85%: p = 0.010; 115%: p

Epidemiologic data of proximal hamstring avulsions have mainly been reported in relatively small patient cohorts. Detailed information on patient demographics, injury mechanism, and injury patterns is lacking in the literature. Since these injuries are rare and frequently misdiagnosed, a better understanding may help to increase awareness and to improve diagnosis of proximal hamstring avulsions. A chart review was performed to identify all patients who had undergone surgical repair for complete proximal hamstring avulsions between 01/2006 and 02/2019 at the authors’ institution. The following demographic and injury-specific data were obtained: Sex, age, body mass index (BMI), cause of injury (sports, activities of daily living, and others), presence of neurologic symptoms referable to the sciatic nerve, time to surgery, injury pattern (affected tendons), tendon retraction, and type of injury according to Wood et al.`s classification (Type 1: osseous avulsions, Type 2: tear at the musculotendinous junction, Type 3: incomplete avulsion from bone, Type 4: complete avulsion with only minimal retraction, and Type 5: complete avulsion with retraction > 2 cm). Data were analyzed for the entire study population and group comparison was performed with regard to sex, cause of injury, and the type of injury. A total of 263 patients were included (53% male). The mean age was 49 ± 13 years with most patients (56%) aged between 45–59 years. Most injuries occurred while participating in sports (52%) and injury type 5 was most commonly diagnosed (66%). Five percent of patients had sensory deficits referable to the sciatic nerve. Gender comparison showed that female patients were significantly older, predominantly represented in the age group 45–59 years, and most commonly injured during activities of daily living, whereas male patients were significantly more often represented in younger age groups, and the most common cause of injury was sports. Compared to Type 4 and 5 injuries, patients with a Type 1 injury were significantly younger and had a significantly longer time to surgery. Proximal hamstring avulsion occurs predominately in the middle-aged patient and only rarely in patients under the age of 30 years. No gender dominance exists. Female patients are typically older and get injured during activities of daily living, whereas male patients are younger and get injured more often during sports. These epidemiologic data may help physicians to make an accurate and early diagnosis. IV.

Several anatomic risk factors associated with patellofemoral disorders have been described. The purpose of this study was to analyze the relationship between bony parameters commonly used to analyze and define patellofemoral malalignment. Patients with patellofemoral disorders presenting between 2016 and 2018 who underwent a standardized radiographic workup including conventional radiographs, weight bearing full-leg radiographs, magnetic resonance imaging (MRI) of the knee, and torsional analysis using hip–knee–ankle MRI were initially included. Patients with a history of lower extremity fracture and a history of surgical procedures affecting bony alignment or partial/total arthroplasty were subsequently excluded. Radiographs and MRI of all included patients were analyzed by four independent observers. Parameters of interest were: femoral torsion, tibial torsion, trochlear dysplasia, tibial tuberosity–trochlear groove (TT–TG) distance, and frontal mechanical axis. All parameters were compared between patients with low grade and high grade trochlear dysplasia as well as between female and male patients. Correlation of continuous variables was assessed with the Pearson correlation coefficient. A binary logistic regression model was used for the calculation of odds ratio between different parameters. Interclass correlation coefficients (ICC) were calculated to determine the interobserver reproducibility. A total of 151 patients could be included for detailed analysis. Group comparison revealed that patients with high grade trochlear dysplasia showed significantly higher values for femoral torsion (low grade: 9.8° ± 11.0°, high grade: 16.8° ± 11.5°; p

Posterior tibial slope (PTS) represents an important risk factor for anterior cruciate ligament (ACL) graft failure, as seen in clinical studies. An anterior closing wedge osteotomy for slope reduction was performed to investigate the effect on ACL-graft forces and femoro-tibial kinematics in an ACL-deficient and ACL-reconstructed knee in a biomechanical setup. Ten cadaveric knees with a relatively high native slope (mean ± SD): (slope 10° ± 1.4°, age 48.2 years ± 5.8) were selected based on prior CT measurements. A 10° anterior closing-wedge osteotomy was fixed with an external fixator in the ACL-deficient and ACL-reconstructed knee (quadruple Semi-T/Gracilis-allograft). Each condition was randomly tested with both the native tibial slope and the post-osteotomy reduced slope. Axial loads (200 N, 400 N), anterior tibial draw (134 N), and combined loads were applied to the tibia while mounted on a free moving and rotating X–Y table. Throughout testing, 3D motion tracking captured anterior tibial translation (ATT) and internal tibial rotation (ITR). Change of forces on the reconstructed ACL-graft (via an attached load-cell) were recorded, as well. ATT was significantly decreased after slope reduction in the ACL-deficient knee by 4.3 mm ± 3.6 (p

This study was conducted to investigate patients’ expectations on high tibial osteotomies, distal femur osteotomies, and double-level osteotomies in different health-related domains. It was hypothesized that expectations are high in terms of capacity to work, pain relief, and restoring knee function. A total of 264 patients (age 47 years ± 11 years) were enrolled in this study from March 2015 until May 2016 in seven specialized orthopaedic surgery departments. Data were collected via the Knee injury and Osteoarthritis Outcome Score, the Hospital for Special Surgery-Knee Surgery Expectations Survey, and a ten-item (non-validated) questionnaire to specifically ask about expectations of osteotomies around the knee 24–48 h prior to surgery. In addition, self-efficacy was assessed. Parametric tests were used to test the hypothesis. Knee injury and Osteoarthritis Outcome Score test results showed that all patients suffered because of their knee impairments prior to surgery. All participants had high expectations in all aspects regarding the surgical outcome: on a four-point Likert scale ranging from 1 (very important) to 4 (not important), all mean values were between 1.2 and 1.7. For patients who had a demanding physical work, the ability to keep a stressful working posture was more important than for other patients (i.e. to kneel, to squat). Furthermore, preoperative lower quality of life was associated with higher expectations concerning improving the ability to walk, to achieve improvements in activities of daily living and social well-being. Patients’ expectations of osteotomies around the knee are high in terms of capacity to work, pain relief, and restoring functions. The natural course of osteoarthritis and the potential need for conversion to TKA were underestimated by a substantial proportion of the study population. However, the expectation regarding survival rate is in line with the reported literature. The results of this study should assist surgeons in discussing realistic expectations when considering and counselling patients regarding osteotomies around the knee. This may help to clarify realistic expectations preoperatively and ultimately improve patients’ satisfaction. Therapeutic study, Level II.

High tibial osteotomy (HTO) is a valid and joint preserving surgical technique to treat medial degenerative osteoarthritis (OA) in young and active patients. A recent study shows that patients’ expectations of osteotomy around the knee are high, but OA progression and potential conversion to a total knee arthroplasty (TKA) were underestimated. The aim of this study was to investigate surgeons’ expectations of HTO and to compare the results to the patients’ expectations and actual outcomes reported in the literature. 461 surgeons were questioned online using the ‘Hospital for Special Surgery Knee Surgery Expectations Survey (HFSS-KSES)’ and a ten-item non-validated questionnaire to investigate the expectations of HTO. Two subgroups were formed to investigate differences regarding the surgeons’ experience. Statistical analysis was performed using IBM SPSS Statistics. Surgeons’ expectations of HTO were rated between very and little important with pain reduction being the most important item on the HFSS-KSES. Furthermore, ‘improving the ability to walk’, ‘to perform daily activities’, ‘having confidence in the knee’, and ‘avoiding future degeneration’ were rated of high importance. An important difference regarding the experience was the lower expectations on delay/prevention of TKA of less-experienced surgeons. Surgeons’ expectations of HTO are high but nevertheless different to the patients’ expectations reported in the literature. Also, expectations for the delay/prevention of TKA differed regarding the experience of surgeons. While pain reduction represents one of the most important items for surgeons and patients, the expected outcome regarding the delay/prevention of a TKA and returning to sports differs to the patients’ expectations and to the actual outcome reported in the literature. This should be considered when performing the preoperative informed consent.

Purpose Trochlear dysplasia is a significant risk factor for patellofemoral instability. The severity of trochlear dysplasia is commonly evaluated based on the Dejour classification in axial MRI slices. However, this often leads to heterogeneous assessments. A software to generate MRI-based 3D models of the knee was developed to ensure more standardized visualization of knee structures. The purpose of this study was to assess the intra- and interobserver agreements of 2D axial MRI slices and an MRI-based 3D software generated model in classification of trochlear dysplasia as described by Dejour. Methods Four investigators independently assessed 38 axial MRI scans for trochlear dysplasia. Analysis was made according to Dejour’s 4 grade classification as well as differentiating between 2 grades: low-grade (types A + B) and high-grade trochlear dysplasia (types C + D). Assessments were repeated following a one-week interval. The inter- and intraobserver agreement was determined using Cohen’s kappa (κ) and Fleiss kappa statistic (κ). In addition, the proportion of observed agreement (po) was calculated for assessment of intraobserver agreement. Results The assessment of the intraobserver reliability with regard to the Dejour-classification showed moderate agreement values both in the 2D (κ = 0.59 ± 0.08 SD) and in the 3D analysis (κ = 0.57 ± 0.08 SD). Considering the 2-grade classification, the 2D (κ = 0.62 ± 0.12 SD) and 3D analysis (κ = 0.61 ± 0.19 SD) each showed good intraobserver matches. The analysis of the interobserver reliability also showed moderate agreement values with differences in the subgroups (2D vs. 3D). The 2D evaluation showed correspondences of κ = 0.48 (Dejour) and κ = 0.46 (high / low). In the assessment based on the 3D models, correspondence values of κ = 0.53 (Dejour) and κ = 0.59 (high / low) were documented. Conclusion Overall, moderate-to-good agreement values were found in all groups. The analysis of the intraobserver reliability showed no relevant differences between 2 and 3D representation, but better agreement values were found in the 2-degree classification. In the analysis of interobserver reliability, better agreement values were found in the 3D compared to the 2D representation. The clinical relevance of this study lies in the superiority of the 3D representation in the assessment of trochlear dysplasia, which is relevant for future analytical procedures as well as surgical planning. Level of evidence Level II.

To specifically evaluate the influence of the acromioclavicular (AC)-joint morphology on the outcome after arthroscopically assisted coracoclavicular (CC) stabilization surgery with suspensory fixation systems and to investigate whether an additional open AC-joint reduction and AC cerclage improves the clinical outcome for patients with certain morphologic AC-joint subtypes.Patients with an acute acromioclavicular joint injury, who underwent arthroscopically assisted CC stabilization with suspensory fixation systems with or without concomitant AC cerclage between January 2009 and June 2017 were identified and included in this retrospective cohort analysis. AC-joint morphology was assessed on preoperative radiographs and categorized as "flat" or "non-flat" ("oblique"/"curved") subtypes. After a minimum of 2 years of follow-up, postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and visual analog scale (VAS) scores for pain were collected. A subgroup analysis of clinical outcomes depending on the surgical technique and morphological subtype of the AC joint was performed.Eighty-one patients (95% male, mean age 35 ± 12 years) could be included at a mean follow-up of 57 ± 14 months. Radiographic assessment of AC-joint morphology showed 24 (30%) cases of flat type, 38 (47%) cases of curved type, and 19 (23%) cases of oblique morphology. Postoperatively, no clinically significant difference could be detected after the treatment of AC joint injury via CC stabilization with or without concomitant AC cerclage (VASIn arthroscopically assisted AC stabilization surgery with suspensory fixation systems for acute AC-joint injury, the AC-joint morphology did not influence the postoperative outcome, independent of the surgical technique. No clinical benefit of performing an additional horizontal stabilization could be detected in our collective at mid-term follow-up.Level IV, therapeutic case series.

Osteotomies around the knee in patients with varus malalignment are commonly used combined with cartilage repair procedures. Malalignment plays a crucial role in the development and hence in the treatment of cartilage defects, since the mechanical alignment of the lower extremity has a great impact on joint loading. Malalignment is an important risk factor for failure of cartilage repair procedures. With the aim of creating optimal biomechanical conditions for the induced or transplanted repair tissue, unloading osteotomies should be part of the standard therapy in cartilage surgery of varus knees.

Purpose Dislocated tibial avulsions of the posterior cruciate ligament (PCL) require surgical intervention. Several arthroscopic strategies are options to fix the fragment and restore posterior laxity, including two types of suspension button devices: adjustable (self-locking) and rigid knotted systems. Our hypothesis was that a rigid knotted button construct has superior biomechanical properties regarding laxity restoration compared with an adjustable system. Both techniques were compared with standard screw fixation and the native PCL. Methods Sixty porcine knees were dissected. The constructs were tested for elongation, stiffness, yield force, load to failure force, and failure mode in a material testing machine. Group N (native, intact PCL) was used as a control group. In group DB (Dogbone™), TR (Tightrope™), and S (screw), a standardized block osteotomy with the osteotomized fragment attached to the PCL was set. The DB and TR groups simulated using a suspension button system with either a rigid knotted (DB) or adjustable system (TR). These groups were compared to a screw technique (S) simulating antegrade screw fixation from posterior. Results Comparing the different techniques (DB, TR, S), no significant elongation was detected; all techniques achieved a sufficient posterior laxity restoration. Significant elongation in the DB and TR group was detected compared with the native PCL (N). In contrast, screw fixation did not lead to significant elongation. The stiffness, yield load, and load to failure force did not differ significantly between the techniques. None of the techniques reached the same level of yield load and load to failure force as the intact state. Conclusion Arthroscopic suspension button techniques sufficiently restore the posterior laxity and gain a comparable construct strength as an open antegrade screw fixation.

Purpose Both acute ruptures of the anterior cruciate ligament (ACL) as well as chronic ACL insufficiency show a high association with focal cartilage defects of the knee. However, the results after combined ACL reconstruction and cartilage repair are not well investigated. The aim of the present study was to investigate the short-term outcomes after autologous chondrocyte implantation (ACI) in combination with ACL reconstruction and to compare the results with patients who underwent isolated ACI in ligament intact knees. Methods All patients who were registered in the German Cartilage Registry with ACI for focal cartilage defects in the knee joint in combination with ACL reconstruction and who completed the 24 month follow-up were included in the study group. A matched-pair procedure according to gender, defect location, defect size, and age was used to create a control group of patients with isolated ACI in ACL intact joints. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the numeric analog scale for pain (NAS) were used to assess the preoperative state as well as the clinical outcomes 12 and 24 months after surgery. Results A total of 34 patients were included in both the study group (age mean 33.3 ± SD 8.8 years) and the control group (33.6 ± 8.4 years) with a median defect size of 466 (25%-75% IQR 375–600) mm2 and 425 (IQR 375–600) mm2, respectively. In comparison with the preoperative state (median 67, IQR 52–75), the study group showed a significant increase of the total KOOS after 12 months (78, IQR 70–86; p = 0.014) and after 24 months (81, IQR 70–84; p = 0.001). The NAS for pain did not change significantly in the postoperative course. In comparison with the control group there was no significant difference for the total KOOS neither preoperative (control group median 67, IQR 52–73) nor at any postoperative time point (12 months: 82, IQR 67–93; 24 months: 81, IQR 71–91). Conclusion The clinical short-term outcomes after ACI at the knee joint in combination with ACL reconstruction are good and similar to the results after isolated ACI in ligament intact knees. Level of evidence III.

Purpose To investigate functional and clinical outcomes, and physical activity after arthroscopic suture fixation of tibial eminence fractures with regard to postoperative stability, range of motion (ROM), complications, and return to sports. Methods Patients undergoing arthroscopic reduction and internal fixation (ARIF) of tibial eminence fractures using a suture fixation technique were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using KT-1000 arthrometer measurements, clinical examination, outcome scores (Lysholm score, Tegner Activity Scale), and a questionnaire about sport activities. Results A total of 23 patients (44% male, 57% female) with a mean age of 25 ± 15 years were included. Mean follow-up was 57 ± 25 months. KT-1000 arthrometer measurements of anterior tibial translation revealed a mean side-to-side difference of 0.9 ± 1.0 mm. Clinical examination showed 100% normal or nearly normal anterior translation of the tibia. Two patients (9%) received an ACL reconstruction due to traumatic ACL re-instability and were, therefore, considered as failures. An extension deficit concerning hyperextension occurred in 29% of patients postoperatively. Further postoperative complications occurred in 14% of patients and included postoperative stiffness with ROM limitations and secondary dislocation of a fragment. Mean postoperative Lysholm score was 89 ± 14. Comparing pre- and postoperative values, no significant change of the Tegner Activity Scale was observed. All patients (failures excluded) returned to high impact sports activities after ARIF. Conclusion Excellent reliable ligamentous stability and high rates of return to high impact sports can be expected after ARIF using a suture fixation technique for type II–IV tibial eminence fractures. Complications, such as limitations in ROM, commonly occur in up to 30% after ARIF. Therefore, regular follow-up examinations remain important in this usually young patient cohort. Level of Evidence Level IV.

PurposeTo analyze whether preoperative patellofemoral anatomy is associated with clinical improvement and failure rate after isolated patellofemoral arthroplasty (PFA) using a modern inlay-type trochlear implant.MethodsProspectively collected 24 months data of patients treated with isolated inlay PFA (HemiCAP®Wave, Arthrosurface, Franklin, MA, USA) between 2009 and 2016, and available digitalized preoperative imaging (plain radiographs in three planes and MRI) were retrospectively analyzed. All patients were evaluated using the WOMAC score, Lysholm score, and VAS pain. Patients revised to TKA or not achieving the minimal clinically important difference (MCID) for the total WOMAC score or VAS pain were considered failures. Preoperative imaging was analyzed regarding the following aspects: Tibiofemoral OA, patellofemoral OA, trochlear dysplasia (Dejour classification), patellar height (Insall–Salvati index [ISI]; Patellotrochlear index [PTI]), and position of the tibial tuberosity (TT–TG and TT–PCL distance).ResultsA total of 41 patients (61% female) with a mean age of 48 ± 13 years could be included. Fifteen patients (37%) were considered failures, with 5 patients (12%) revised to TKA and 10 patients (24%) not achieving MCID for WOMAC total or VAS pain. Failures had a significantly higher ISI, and a significantly lower PTI. Furthermore, the proportion of patients with a pathologic ISI (> 1.2), a pathologic PTI (ConclusionPreoperative patellofemoral anatomy is significantly associated with clinical improvement and failure rate after isolated inlay PFA. Less improvement and a higher failure rate must be expected in patients with patella alta (ISI > 1.2 and PTI 21 mm). Concomitant procedures such as tibial tuberosity transfer may, therefore, be considered in such patients.Level of evidenceLevel III, retrospective analysis of prospectively collected data.

PurposeTo perform a detailed deformity analysis of patients with varus alignment and to define the ideal osteotomy level (tibial vs. femoral vs. double level) to avoid an oblique joint line.MethodsA total of 303 digital full-leg standing radiographs of patients aged 18–60 years and varus alignment [mechanical tibiofemoral varus angle (mFTA) ≥ 3°] were included. All legs were analyzed regarding mFTA, mechanical medial proximal tibia angle (mMPTA), mechanical lateral distal femur angle (mLDFA), and joint line convergence angle. Based on mFTA, varus alignment was categorized as “mild” (3°–5°), “moderate” (6°–8°), or “severe” (≥ 9°). Deformity location was determined according to the malalignment test described by Paley. Two osteotomy simulations were performed with different upper limits for mMPTA: anatomic correction (mMPTA ≤ 90°, mLDFA ≥ 85°) and overcorrection (mMPTA ≤ 95°, mLDFA ≥ 85°). If a single osteotomy exceeded these limits at the intended mFTA of 2° valgus, a double-level osteotomy was simulated. If even a double-level osteotomy resulted in deviations from the defined limits, the leg was categorized as “uncorrectable”.ResultsMean mFTA was 6° ± 11° of varus (range 3°–15°). A tibial deformity was observed in 28%, a femoral deformity in 23%, a combined tibial and femoral deformity in 4%, and no bony deformity in 45%. The prevalence of a tibial deformity did not differ between varus severity groups, whereas a femoral and bifocal deformity was significantly more prevalent in knees with more distinct varus (p p p p p ConclusionLess than one-third of patients (28%) with mechanical varus ≥ 3° have a tibial deformity. If anatomic correction (mMPTA ≤ 90°) is intended, only 12% of patients can be corrected via isolated HTO, whereas 63% of patients require a double-level osteotomy. If slight overcorrection is accepted (mMPTA ≤ 95°), 57% of patients can be corrected via isolated HTO, whereas 33% of patients would still require a double-level osteotomy.Level of evidenceIII, cross-sectional study.

Background: Reconstruction of the medial patellofemoral ligament (MPFL) has become a popular surgical procedure to address patellofemoral instability. As a consequence of the growing number of MPFL reconstructions performed, a higher rate of failures and revision procedures has been seen. Purpose: To perform a failure analysis in patients with patellar redislocation after primary isolated MPFL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing revision surgery for reinstability after primary isolated MPFL reconstruction were included. Clinical notes were reviewed to collect demographic data, information on the primary surgery, and the mechanism of patellar redislocation (traumatic vs nontraumatic). Preoperative imaging was analyzed regarding femoral tunnel position and the prevalence of anatomic risk factors (ARFs) associated with patellofemoral instability: trochlear dysplasia (types B through D), patella alta (Caton-Deschamps index >1.2, patellotrochlear index 20 mm, tibial tuberosity–posterior cruciate ligament [TT-PCL] distance >24 mm), valgus malalignment (mechanical valgus axis >5°), and torsional deformity (internal femoral torsion >25°, external tibial torsion >35°). The prevalence of ARF was compared between patients with traumatic and nontraumatic redislocations and between patients with anatomic and nonanatomic femoral tunnel position. Results: A total of 26 patients (69% female) with a mean age of 25 ± 7 years were included. The cause of redislocation was traumatic in 31% and nontraumatic in 69%. Position of the femoral tunnel was considered nonanatomic in 50% of patients. Trochlear dysplasia was the most common ARF with a prevalence of 50%, followed by elevated TT-PCL distance (36%) and valgus malalignment (35%). The median number of ARFs per patient was 3 (range, 0-6), and 65% of patients had 2 or more ARFs. Patients with nontraumatic redislocations showed significantly more ARFs per patient, and the presence of 2 or more ARFs was significantly more common in this group. No significant difference was observed between patients with anatomic versus nonanatomic femoral tunnel position. Conclusion: Multiple anatomic risk factors and femoral tunnel malposition are commonly observed in patients with reinstability after primary MPFL reconstruction. Before revision surgery, a focused clinical examination and adequate imaging including radiographs, magnetic resonance imaging (MRI), standing full-leg radiographs, and torsional measurement with computed tomography or MRI are recommended to assess all relevant anatomic parameters to understand an individual patient’s risk profile. During revision surgery, care must be taken to ensure anatomic placement of the femoral tunnel through use of anatomic and/or radiographic landmarks.

To determine the prevalence of a deep lateral femoral notch sign (LFNS) in magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus (PLRT).A retrospective chart review was conducted to identify all patients undergoing ACL reconstruction between 2016 and 2018. Based on the arthroscopic appearance of the lateral meniscus, patients were assorted to one of three groups: isolated ACL tear (ACL-Group), ACL tear with concomitant lateral meniscus tear not involving the posterolateral root (Meniscus-Group), and ACL tear with concomitant PLRT (PLRT-Group). Incidence and depth of a LFNS on preoperative MRI was compared between the three cohorts.115 patients (mean age: 29.5 ± 11.3 years) were included in the study, with 58 patients (50.4%) assorted to the ACL-Group, 24 patients (20.9%) to the Meniscus-Group, and 33 patients (28.7%) to the PLRT-Group. The prevalence of a LFNS was significantly higher in the PLRT-Group (39.4%), when compared to the ACL- (5.2%) or Meniscus-Groups (25.0%; p 0.001, respectively). Additionally, logistic regression analysis demonstrated that patients with PLRT were 5.3 times more likely to have a LFNS as compared to those without a lateral root tear (p 0.001).In patients with ACL tears, the presence of a LFNS on preoperative MRI may be predictive for a PLRT. As the LFNS occurs in almost 40% of the patients with combined ACL tears and PLRT, the LFNS may be a useful secondary diagnostic finding in early MRI diagnostic. Identifying PLRT on MRI is clinically relevant, as it prevents misdiagnosis and facilitates surgical decision-making, thus avoiding subsequent delayed treatment.Level IV.

Background Biodegradable implants have gained increasing importance for the fixation of simple displaced radial head fractures to supersede implant removal and to minimize cartilage destruction. Commonly used polylactide pins still lead to higher rates of secondary loss of reduction compared with metal implants. Alternatively, implants made from a magnesium alloy meanwhile are available in a pin design that hypothetically could perform better than polylactide pins. Because biomechanical data of clinical applications are lacking, the goal of the present study was to biomechanically compare magnesium pins to polylactide pins using a Mason type II radial head fracture model. Methods Fourteen pairs of fresh-frozen human cadaver radii with a standardized Mason type II radial head fracture were stabilized either by two 2.0-mm polylactide pins (PPs) or two 2.0-mm magnesium pins (MPs). Biomechanical in vitro testing was conducted as 10 cycles of static loading at 0.1 Hz axially and transversally between 10 and 50 N. Afterward, loosening was tested by dynamic load changes at 4 Hz up to 100,000 cycles. Early fracture displacement was measured after 10,000 cycles. Afterward, maximum loads were raised every 10,000 cycles by 15 N until construct failure, which was defined as fracture displacement ≥2 mm. Results MP osteosynthesis showed a tendency toward higher primary stability on both axial (MP: 0.19 kN/mm, PP: 0.11 kN/mm; P = .068) and transversal loading (MP: 0.11 kN/mm, PP: 0.10 kN/mm; P = .068). Early fracture displacement was significantly higher following PP osteosynthesis (MP: 0.3 mm, PP: 0.7 mm; P = .030). The superiority of MP was also significant during cyclic loading, represented in a higher failure cycle (MP: 30,684, PP: 5113; P = .009) and in higher failure loads (MP: 95 N, PP: 50 N; P = .024). Conclusion According to our findings, in simple radial head fractures, osteosynthesis with magnesium pins show superior biomechanical properties compared with fractures treated by polylactide pins. Prospective investigations should follow to evaluate clinical outcomes and resorption behavior.

Anatomic repair of the torn meniscal root using transosseous sutures through the proximal tibia. Nontraumatic meniscal root tears without severe degenerative changes (Kellgren–Lawrence grade ≤ 2), good quality meniscal tissue, traumatic root tears with or without concomitant anterior cruciate ligament tears or multiligament injuries. Uncorrected varus or valgus malalignment (>3°), osteoarthritis Kellgren–Lawrence grades III and IV, and diffuse articular cartilage changes International Cartilage Regeneration and Joint Preservation Society (ICRS) grades III and IV of the effected compartment, noncompliance. Root tear confirmed by probing; location for the planned root refixation on the tibial plateau is identified. A tibial socket or full transtibial tunnel created with an aiming drill guide. Using a self-retrieving suture passing device or a curved suture passer, the torn meniscus root sutured with no. 0 non-absorbable braided suture. Meniscal sutures passed through the tibial tunnel and the meniscus root reduced into the socket or tunnel by tensioning the free ends of the sutures, followed by fixation on the tibial cortex. Toe touch weight-bearing for 6 weeks, restricted range of motion (0–60° of flexion) for 6 weeks, no axial loading at flexion angles >90° until 6 months postoperatively. For medial root tears, pullout repair significantly improves functional outcome scores and seems to prevent the progression of osteoarthritis in the short-term. Complete healing observed in only 60% of patients. Negative prognostic factors: varus malalignment > 5°, cartilage degeneration Outerbridge grade III and IV, and older age. Outcomes after lateral root repair are encouraging with apparent prevention of progression of osteoarthritis.

Zusammenfassung Das hochste Risiko einer Reruptur der primaren VKB-Plastik haben junge, sportliche Athleten im Alter zwischen 15 und 20 Jahren. Haufig tritt diese innerhalb der ersten 2 Jahre nach der primaren Operation auf. Ursachlich fur eine erneute Instabilitat konnen neben einem Versagen des Transplantates im Rahmen eines adaquaten Traumas eine fehlende biologische Heilung oder ein technischer Fehler sein. Entsprechend ist eine genaue Ursachenanalyse notwendig, um den Revisionseingriff zu planen. Neben der klinischen Untersuchung ist hier eine erweiterte Bildgebung notwendig. Des Weiteren ist es entscheidend, sich ein Bild uber die bereits verwendeten Transplantate zu machen und diese mit in die Strategie der Revision einzubeziehen. Wesentlich fur den Erfolg nach einer Revision einer VKB-Plastik ist die realistische Erwartungshaltung und die kontrollierte Wiederkehr zum Sport.

High tibial osteotomy (HTO) has gained more importance in the treatment of cartilage damage or osteoarthritis of the medial compartment with concurrent varus deformity. Concerning the extent of axis correction, various different views exist. The aim of this study was to evaluate the effect of the size of axis correction on functional outcome in patients undergoing a valgus HTO. From 2005 to 2013, 156 patients with an underlying varus deformity and cartilage damages or unicompartimental osteoarthritis of the medial compartment were treated by HTO. Retrospectively patients were allocated into three different groups according to the degree of axis correction. For this purpose, three adjacent areas, respectively, comprising 5% of the tibial plateau were defined. Limits of those areas were set as follows: with the medial border representing the 0% point and the lateral border representing the 100 point, the three areas were separated according to their limiting intersection points (group A 50–55%, group B 55–60%, group C > 60%). For comparison of the functional outcomes, standardized measures and scores were used (pre-OP: VAS, Lysholm; post-OP: VAS, Lysholm, KOOS). Analysis of the pre- and post-operatively recorded X-rays was effected by means of a planning software (mediCAD, Hectec GmbH, Germany), and statistical analysis was carried out using SPSS Statistics 21.0 (IBM Corp., Armonk, USA). A p value of 0.05 was considered statistically significant. Thirty-nine patients were allocated to group A, 50 patients to group B and 67 to group C. Pre-operatively, patients in each group were of a homogenous constitution. In the groups A–C, HTO proved to reduce the VAS score and to increase the Lysholm score (p