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Purpose: The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient., Methods: For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement., Results: During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus., Conclusions: This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon., Level of Evidence: Level V., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: Injuries to the elbow are frequent in judo combat, but studies on down-time and effect on performance after conservative treatments are rare. This issue is particularly relevant for elbow dislocations in high-performance patients such as elite athletes. The purpose of this study was to evaluate (1) time-loss and (2) the regained level of performance in judoka after conservative treatment of simple elbow dislocation., Methods: In cooperation with the European Judo Union, judoka were asked to complete a 139-item survey regarding elbow injuries they suffered during their career. Besides demographics, injury data, diagnosis and treatment options, the athletes were asked about down-time and reductions in performance level. This study enrolled 108 judoka with conservative treatment of elbow dislocation out of a population of 5426 volunteers., Results: 69% (n=74) reported a time-loss of less than three months; 6% reported a time-loss of more than six months. The majority (68%, n=73) reported that they had returned to their previous performance level, while 22% (n=24) suffered from a slightly reduced level of performance. In the subgroup of international and national athletes (n=54), 63% returned to judo after less than three months, with 72% achieving the same level and 15% reporting a slightly reduced performance level. Level of performance and time lost after conservative treatment for elbow dislocations were comparable for male and female judoka., Conclusion: Approximately two out of three judoka returned to the same level of performance after three months of down-time after undergoing conservative therapy for simple elbow dislocations. Despite the high performance level of the study population, conservative treatment of simple elbow dislocation resulted in satisfactory outcomes. The presented data can guide medical professionals and competitive-level contact-sport athletes with respect to expectations in the process of returning to sport., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: The aim of this consensus project was to validate which endogenous and exogenous factors contribute to the development of post-traumatic osteoarthritis and to what extent ACL (anterior cruciate ligament) reconstruction can prevent secondary damage to the knee joint. Based on these findings, an algorithm for the management after ACL rupture should be established., Methods: The consensus project was initiated by the Ligament Injuries Committee of the German Knee Society (Deutsche Kniegesellschaft, DKG). A modified Delphi process was used to answer scientific questions. This process was based on key topic complexes previously formed during an initial face-to-face meeting of the steering group with the expert group. For each key topic, a comprehensive review of available literature was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Consensus was defined a-priori as eighty percent agreement., Results: Of the 17 final statements, 15 achieved consensus, and 2 have not reached consensus. Results of the consensus were summarized in an algorithm for the management after ACL rupture (infographic/Fig. 2)., Conclusion: This consensus process has shown that the development of post-traumatic osteoarthritis is a complex multifactorial process. Exogenous (primary and secondary meniscus lesions) and endogenous factors (varus deformity) play a decisive role. Due to the complex interplay of these factors, an ACL reconstruction cannot always halt post-traumatic osteoarthritis of the knee. However, there is evidence that ACL reconstruction can prevent secondary joint damage such as meniscus lesions and that the success of meniscus repair is higher with simultaneous ACL reconstruction. Therefore, we recommend ACL reconstruction in case of a combined injury of the ACL and a meniscus lesion which is suitable for repair., Level of Evidence: Level V., (© 2022. The Author(s).)

Purpose: The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process., Methods: For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement., Results: During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus., Conclusions: This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient., Level of Evidence: Level V., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Objectives: Implementing evidence-based recommendations with the option of patient-individualised and situation-specific adaptations in telerehabilitation may increase adherence with improved clinical outcome., Methods: As part of a registry-embedded hybrid design (part 1), digital medical device (DMD)-usage in a home-based setting was analysed in a multinational registry. The DMD combines an inertial motion-sensor system with instructions for exercises and functional tests on smartphones. A prospective, single-blinded, patient-controlled, multicentre intervention study (DRKS00023857) compared implementation capacity of the DMD to standard physiotherapy (part 2). Usage patterns by health care providers (HCP) were assessed (part 3)., Results and Conclusion: Registry raw data (10,311 measurements) were analysed from 604 DMD-users, demonstrating clinically expected rehabilitation progression post knee injuries. DMD-users performed tests for range-of-motion, coordination and strength/speed enabling insight to stage-specific rehabilitation (χ2 = 44.9, p<0.001). Intention-to-treat-analysis (part 2) revealed DMD-users to have significantly higher adherence to the rehabilitation intervention compared to the matched patient-control-group (86% [77-91] vs. 74% [68-82], p<0.05). DMD-users performed recommended exercises at home with higher intensity (p<0.05). HCP used DMD for clinical decision making. No adverse events related to the DMD were reported. Adherence to standard therapy recommendations can be increased using novel high quality DMD with high potential to improve clinical rehabilitation outcome, enabling evidence-based telerehabilitation., Competing Interests: JS, WP, NM, DN, TS, TSto and RS and are medical consultants of OPED GmbH., (Copyright: © 2023 Höher et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Different indications and treatment options for combined injuries to the anterior cruciate ligament (ACL) and medial collateral ligament complex (MCL) are not clearly defined., Purpose: To perform a modified Delphi process with the Committee for Ligament Injuries of the German Knee Society (DKG) in order to structure and optimize the process of treating a combined injury to the ACL and MCL., Study Design: Consensus statement., Methods: Scientific questions and answers were created based on a comprehensive literature review using the central registers for controlled studies of Medline, Scopus, and Cochrane including the terms medial collateral ligament , anterior cruciate ligament , MCL , ACL , and outcome used in various combinations. The obtained statements passed 3 cycles of a modified Delphi process during which each was readjusted and rated according to the available evidence (grades A-E) by the members of the DKG Ligament Injuries Committee and its registered guests., Results: The majority of answers, including several questions with >1 graded answer, were evaluated as grade E (n = 16) or C (n = 10), indicating that a low level of scientific evidence was available for most of the answers. Only 5 answers were graded better than C: 3 answers with a grade of A and 2 answers with a grade of B. Only 1 answer was evaluated as grade D. An agreement of >80% (range, 83%-100%) among committee members was achieved for all statements., Conclusion: The results of this modified Delphi process offer a guideline for standardized patient care in cases of combined injuries to the ACL and MCL., Competing Interests: The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Background: Stand-up paddleboarding (SUP) is a water sport that has gained in popularity. Still, very little is known about its injury profile., Purpose: To analyze the incidence, mechanisms, and risk factors for SUP-related injuries in mainly calm waters and the use of safety equipment., Study Design: Descriptive epidemiology study., Methods: The authors distributed an online survey that gathered information on characteristics, injury history over the past 12 months, use of (safety) equipment, and health issues of SUP riders in German-speaking countries., Results: A total of 438 participants completed the survey. The mean participant age was 45 years (range, 8-82 years), 48% were female athletes, and 19.6% took part in competitions. Over the past 12 months, 72 (17%) of 431 respondents experienced a SUP-related injury, resulting in an overall incidence rate (IR) of 1.95 injuries per 1000 hours of activity. Male competitive athletes using a hardboard had the highest risk of injury. The IR for competitive riders was higher (3.21 injuries per 1000 hours) than that for recreational riders (1.41 injuries per 1000 hours). Mechanisms of injury were overuse (n = 29) and contact with the board (n = 18) or ground (n = 12). Injuries affected mainly muscles/tendons and joints of the upper arm/shoulder (n = 20), followed by wrist/hand (n = 18), knee (n = 16), elbow/forearm (n = 12), and foot (n = 11). The highest risk of injury occurred when paddling in wild water (33.3%), followed by SUP surfing (29.4%), and the lowest risk occurred while paddling on a lake (16.1%). A life vest was always used by 27, depending on the situation by 201, and never by 202 participants; a leash was always used by 161, depending on the situation by 244, and never by 26 participants. Of the 272 participants who paddled in winter, 253 wore a drysuit or wetsuit, whereas 19 paddled without any special clothing., Conclusion: SUP-related injuries predominantly happened in wild water or while SUP surfing, and male competitive athletes using a hardboard had the highest risk of injury. The main mechanisms of injury were overuse and hitting the board or ground. The upper extremity was more prone to injury, followed by the knee and foot. More effort should be made to educate paddlers on the necessity and correct use of the life vest, leash, and specialized outfits., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Purpose: To investigate whether pre-soaking the graft in vancomycin during anterior cruciate ligament reconstruction (ACLR) reduces the postoperative infection rate and if this technique is associated with an increased rate of complications, including graft failure or arthrofibrosis., Methods: A retrospective review of a prospective database was performed in 1779 patients who underwent ACLR over a period of 5 years, analysing the rate of postoperative deep knee infection. Group 1 and 2 both received perioperative IV antibiotics, while only group 2 underwent ACLR with grafts pre-soaked in a 5 mg/ml vancomycin solution. To analyse possible side effects associated with vancomycin use, 500 patients out of the overall study population (100 patients per year) were randomly selected and retrospectively interviewed for further postoperative complications including graft failure and arthrofibrosis as well as subjective evaluation of their knee by completing the IKDC form with a minimum mean follow-up of 37 months., Results: In group 1, 22 out of 926 (2%) patients suffered a postoperative deep knee infection. In contrast, there were no postoperative infections in the second group of 853 patients (0%). 16 of 22 infections (73%) were caused by coagulase-negative Staphylococcus. Statistical analysis revealed a significantly reduced postoperative infection rate when bathing the autograft in vancomycin (p < 0.01). Analysis of the random sample revealed a significant decrease of graft failure with 8 reruptures in 257 patients (3%) in the vancomycin group compared to 16 cases of graft failure in 167 patients (10%) in the control group (p < 0.05). No differences were found in the rate of postoperative arthrofibrosis, Tegner or subjective outcome scores., Conclusion: Prophylactic vancomycin pre-soaking of autografts during ACLR appears to be a viable, cost-effective and safe option to reduce the rate of deep infection compared to systemic antibiotics alone., Level of Evidence: III.

Background: Although anterior cruciate ligament (ACL) tear-prevention programs may be effective in the (secondary) prevention of a subsequent ACL injury, little is known, yet, on their effectiveness and feasibility. This study assesses the effects and implementation capacity of a secondary preventive motor-control training (the Stop-X program) after ACL reconstruction., Methods and Design: A multicenter, single-blind, randomized controlled, prospective, superiority, two-arm design is adopted. Subsequent patients (18-35 years) with primary arthroscopic unilateral ACL reconstruction with autologous hamstring graft are enrolled. Postoperative guideline rehabilitation plus Classic follow-up treatment and guideline rehabilitation plus the Stop-X intervention will be compared. The onset of the Stop-X program as part of the postoperative follow-up treatment is individualized and function based. The participants must be released for the training components. The endpoint is the unrestricted return to sport (RTS) decision. Before (where applicable) reconstruction and after the clearance for the intervention (aimed at 4-8 months post surgery) until the unrestricted RTS decision (but at least until 12 months post surgery), all outcomes will be assessed once a month. Each participant is consequently measured at least five times to a maximum of 12 times. Twelve, 18 and 24 months after the surgery, follow-up-measurements and recurrence monitoring will follow. The primary outcome assessement (normalized knee-separation distance at the Drop Jump Screening Test (DJST)) is followed by the functional secondary outcomes assessements. The latter consist of quality assessments during simple (combined) balance side, balance front and single-leg hops for distance. All hop/jump tests are self-administered and filmed from the frontal view (3-m distance). All videos are transferred using safe big content transfer and subsequently (and blinded) expertly video-rated. Secondary outcomes are questionnaires on patient-reported knee function, kinesiophobia, RTS after ACL injury and training/therapy volume (frequency - intensity - type and time). All questionnaires are completed online using the participants' pseudonym only. Group allocation is executed randomly. The training intervention (Stop-X arm) consists of self-administered home-based exercises. The exercises are step-wise graduated and follow wound healing and functional restoration criteria. The training frequency for both arms is scheduled to be three times per week, each time for a 30 min duration. The program follows current (secondary) prevention guidelines. Repeated measurements gain-score analyses using analyses of (co-)variance are performed for all outcomes., Trial Registration: German Clinical Trials Register, identification number DRKS00015313 . Registered on 1 October 2018.

Background: The objective of the study was to compare the results of a primary anterior cruciate ligament reconstruction (ACLR) using the press-fit fixation technique for a quadriceps tendon (QT) graft to a standard quadrupled hamstring (HT) graft with interference screw fixation., Methods: A retrospective cohort study with a 12-month follow up provided data for 92 patients. Exclusion criteria were accompanying ligament injuries and contralateral ACL injury. Patients who suffered a graft failure, which was defined as a side-to-side difference of > 3 mm, or infection were rated 'D' according to the IKDC and excluded from further evaluation. Forty-six patients underwent primary ACLR using the press-fit fixation technique for autologous bone QT graft. These patients were matched in terms of age, gender, accompanying meniscus tear and cartilage injury to 46 patients who underwent standard HT graft with interference screw fixation. Patients were evaluated according to the Lachman test, Pivot-Shift test, IKDC score, Tegner score, Rolimeter measurements, one-leg hop test, thigh circumference and donor side morbidity., Results: No significant differences in Tegner score (p = 0.9), subjective or objective IKDC score (p = 0.9;p = 0.6), knee stability (Lachman Test p = 0.6; Pivot-Shift Test p = 0.4; Side-to-Side Difference p = 0.4), functioning testing (One-Leg Hop Test p = 0.6; Thigh Circumference p = 0.4) or donor side morbidity (p = 0.4) were observed at the follow up. The Lachman test was negative for 85% of the QT group and 83% of the HT group. The Pivot Shift Test was negative for 80% of the QT group and 85% of the HT group. The mean side-to-side difference was 1.6 ± 0 .2mm in both groups. The one-leg hop test revealed a collateral-side jumping distance of 96.2 ± 8.5% for the QT group and 95.5 ± 8.5% for the HT group. The thigh circumference of the injured leg was 98.3 ± 3.0% on the uninjured side in the QT group and 99.7 ± 3.0% in the HT group. A knee walking test resulted in no discomfort for 90% of the QT group and 85% of the HT group. The graft failure rate was 7.3% in the QT group and 9.8% in the HT group., Conclusion: QT grafts fixated using the press-fit technique are a reliable alternative for primary ACL surgery.

Background: Recent literature correlated anterior cruciate ligament (ACL) reconstruction failure to smaller diameter of the harvested hamstring (HS) autograft. However, this approach may be a simplification, as relation of graft size to native ACL size is not typically assessed and oversized grafts may impart their own complications., Purpose: To evaluate in vivo data to determine if the commonly used autografts reliably restore native ACL size., Study Design: Descriptive laboratory study., Methods: Intraoperative data of the tibial insertion area and HS graft diameter were collected and retrospectively evaluated for 46 patients who underwent ACL reconstruction with HS autografts. Magnetic resonance imaging measurements of the cross-sectional area (CSA) of the possible patellar tendon (PT) and quadriceps tendon (QT) autografts were also done for each patient. The percentages of tibial insertion site area restored by the 3 possible grafts were then calculated and compared for each individual., Results: The mean ACL tibial insertion area was 107.2 mm 2 (60.5-155.5 mm 2 ). The mean CSAs of PT, HS, and QT were 33.2, 55.3, and 71.4 mm 2 , respectively. When all grafts were evaluated, the percentage reconstruction of the insertion area varied from 16.2% to 123.1% on the tibial site and from 25.5% to 176.7% on the femoral site, differing significantly for each graft type ( P < .05). On average, 32.8% of the tibial insertion area would have been filled with PT, 53.6% by HS, and 69.5% by QT. Based on previous cadaveric studies indicating that graft size goal should be 50.2% ± 15% of the tibial insertion area, 82.7% of patients in the HS group were within this range (36.9%, QT; 30.5%, PT), while 65.2% in the PT group were below it and 60.9% in the QT group were above it., Conclusion: ACL insertion size and the CSAs of 3 commonly used grafts vary greatly for each patient and are not correlated with one another. Thus, if the reconstructed ACL size is determined by the harvested autograft size alone, native ACL size may not be adequately restored. PT grafts tended to undersize the native ACL, while QT might oversize it., Clinical Relevance: These results may help surgeons in preoperative planning, as magnetic resonance imaging measurements can be helpful in determining individualized graft choice to adequately restore the native ACL.

Background: Sport injury severity can be detected by duration of time loss and reduction of sporting performance., Aim: To detect injury type-specific time loss duration and sporting performance reduction in judo., Methods: An online survey of active and former judo athletes was conducted (exclusion criterion: incomplete questionnaire). Only injuries causing more than 3 weeks' time loss were recorded. Athletes classified themselves into performance classes. Injury type-specific frequencies were recorded according to gender, age and performance level. Injury severity was assessed by time loss duration and performance reduction., Results: The study included 4659 athletes (65% male, 38% competitive sports). The most commonly injured body regions were the upper extremity (41%) and the lower extremity (39%). Anterior cruciate ligament (ACL) ruptures were the most severe injury type (time loss: 4% of cases 3-6 weeks, 6% 6-12 weeks, 26% 3-6 months, 32% 6-9 months, 18% 9-12 months, 14%>12 months; performance reduction: 32% same level, 39% slightly reduced, 24% strongly reduced, 5% stopped judo). The second most severe type of injury was a vertebral disc prolapse (time loss: 26% 3-6 weeks, 31% 6-12 weeks, 20% 3-6 months, 7% 6-9 months, 3% 9-12 months 13%>12 months; reduction of sporting performance: 39% same level, 34% slightly reduced, 20% strongly reduced, 8% stopped judo)., Conclusion: Across genders and performance levels, ACL ruptures and vertebral disc prolapses were the most severe injuries with respect to time loss and sporting performance reduction., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The posterior oblique ligament (POL) is the main component of the posteromedial corner (PMC) of the knee and plays a crucial role in acting as a secondary restraint against translation, rotation, and valgus forces. Injuries to the PMC often occur in association with acute or chronic deficiency of the anterior cruciate ligament and may result in anteromedial rotatory instability. A surgical technique for treatment of acute and chronic injuries of the posteromedial structures was first established by Hughston in 1973. This procedure involves an advancement and reefing of the POL and adherent posterior capsule to the stout tissue of the intact medial collateral ligament, potentially using suture anchors if the POL tissue is detached from bone. Additionally, in cases of residual laxity, the semimembranosus tendon may be advanced anteriorly to improve dynamic stabilization. This procedure appears to be useful in cases of moderate posteromedial insufficiency and avoids retrieval of a medial tendon graft from the region of the medially stabilizing hamstrings or from the healthy contralateral side.

Background: Bone tunnel enlargement is a phenomenon present in all anterior cruciate ligament (ACL)- reconstruction techniques. It was hypothesized that press-fit fixation using a free autograft bone plug reduces the overall tunnel size in the tibial tunnel., Methods: In a prospective cohort study twelve patients who underwent primary ACL reconstruction using an autologous quadriceps tendon graft and adding a free bone block for press-fit fixation (PF) in the tibial tunnel were matched to twelve patients who underwent ACL reconstruction with a hamstring graft and interference screw fixation (IF). The diameters of the bone tunnels were analysed by a multiplanar reconstruction technique (MPR) in a CT scan three months postoperatively. Manual and instrumental laxity (Lachman test, Pivot-shift test, Rolimeter) and functional outcome scores (International Knee Documentation Committee sore, Tegner activity level) were measured after one year follow up., Results: In the PF group the mean bone tunnel diameter at the level of the joint entrance was not significantly enlarged. One and two centimeter distal to the bone tunnel diameter was reduced by 15% (p = .001). In the IF group the bone tunnel at the level of the joint entrance was enlarged by 14% (p = .001). One and two centimeter distal to the joint line the IF group showed a widening of the bone tunnel by 21% (p < .001) One and two centimeter below the joint line the bone tunnel was smaller in the PF group when compared to the IF group (p < .001). No significant difference for laxity test and functional outcome scores could be shown., Conclusion: This study demonstrates that press-fit fixation with free autologous bone plugs in the tibial tunnel results in significantly smaller diameter of the tibial tunnel compared to interference screw fixation.

Purpose: The quantification of posterior knee laxity is crucial in the evaluation of injuries to the posterior cruciate ligament (PCL) as it has important implications to the treatment for these injuries. The objective of this study was to compare the test results of stress radiography and instrumented drawer testing (Rolimeter) for the assessment of posterior knee laxity in patients with PCL injury., Methods: In 45 patients with an injury to the PCL, lateral radiographs of both knees were obtained under anterior and posterior tibial load (150 N) using a standardized approach. Patients with injury of the ACL to either knee were excluded from the study. During the same clinic visit, an instrumented measurement of anterior-posterior knee laxity was performed at 90° of knee flexion by an experienced examiner using the Rolimeter device. The mean side-to-side differences (SSD) of both (radiographic and instrumented) measurements were compared to each other, and the correlation was calculated using the Pearson coefficient., Results: The SSD (affected/healthy side) of posterior translation determined from the radiographs was 8.2 ± 3.2 mm, and the SSD of the instrumented measurement testing was 7.6 ± 3.2 mm. The mean difference between radiographic and Rolimeter test results was 1.8 ± 1.5 mm. The Pearson's correlation coefficient revealed a good correlation between both measurements of 0.74., Conclusions: It may be suggested by the results of this study that under the absence of an ACL injury and a fixed posterior drawer sign, the Rolimeter is a suitable tool to assess the posterior laxity of the knee in the clinical setting. Its advantages are the absence of radiation to the patient, its availability, and the low cost. Therefore, the Rolimeter device may serve as a valuable alternative to stress radiography in the evaluation of PCL-injured patients., Level of Evidence: II.

Background: The use of interference screws for femoral graft fixation in anterior cruciate ligament (ACL) reconstruction with hamstring grafts can result in rotation of the graft around the screw leading to changes in the final position of the graft within the bone tunnel., Material and Methods: In a prospective study 107 patients (54 right and 53 left knees) underwent ACL reconstruction with a hamstring tendon autograft. Femoral fixation of the graft was performed with a standard right-thread screw in all cases. Patients were assessed at 6 months postoperatively with the international knee documentation committee (IKDC) standard evaluation including instrumented laxity measurements and the results were compared between right and left knees., Results: A significantly higher postoperative anterior laxity was observed in left knees with a negative Lachman test in only 64 % of the cases compared with 87 % in the group of right knees. Accordingly, instrumented laxity measurements of the reconstructed knee compared with the contralateral knee revealed significant differences between left and right knees (left knees 1.8±1.2 mm and right knees 1.0±1.4 mm)., Conclusions: This study demonstrates the importance of femoral graft positioning and its sensitivity to multiple influencing factors. The use of standard right-thread interference screws for femoral graft fixation in the mirrored situation of right and left knees may produce a systematic error in ACL reconstruction. Due to a possible rotation of the graft around the screw, the final position of the transplant may vary thus leading to significant changes in anterior translation of the operated knee.

Background: The use of interference screws for femoral graft fixation in anterior cruciate ligament (ACL) reconstruction with hamstring grafts can result in rotation of the graft around the screw leading to changes in the final position of the graft within the bone tunnel., Material and Methods: In a prospective study 107 patients (54 right and 53 left knees) underwent ACL reconstruction with a hamstring tendon autograft. Femoral fixation of the graft was performed with a standard right-thread screw in all cases. Patients were assessed at 6 months postoperatively with the international knee documentation committee (IKDC) standard evaluation including instrumented laxity measurements and the results were compared between right and left knees., Results: A significantly higher postoperative anterior laxity was observed in left knees with a negative Lachman test in only 64 % of the cases compared with 87 % in the group of right knees. Accordingly, instrumented laxity measurements of the reconstructed knee compared with the contralateral knee revealed significant differences between left and right knees (left knees 1.8±1.2 mm and right knees 1.0±1.4 mm), Conclusions: This study demonstrates the importance of femoral graft positioning and its sensitivity to multiple influencing factors. The use of standard right-thread interference screws for femoral graft fixation in the mirrored situation of right and left knees may produce a systematic error in ACL reconstruction. Due to a possible rotation of the graft around the screw, the final position of the transplant may vary thus leading to significant changes in anterior translation of the operated knee.

Background: Patients with a history of anterior cruciate ligament rupture are at elevated risk of developing knee osteoarthritis. Altered knee kinematics and kinetics during functional activities have been viewed as risk factors for cartilage breakdown and, therefore, one of the primary goals of anterior cruciate ligament reconstruction is to restore knee joint function., Methods: Patients' (n=18) knee mechanics while performing a single leg hop for distance were calculated for both legs using a soft-tissue artifact optimized rigid lower-body model at the pre-reconstruction state and six and twelve months after anterior cruciate ligament reconstruction., Findings: Independent of the analyzed time point the involved leg showed a lower external flexion and adduction moment at the knee, and an increased anterior translation and external rotational offset of the shank with respect to the thigh compared to the uninvolved leg. There were no differences for any of the analyzed knee kinematic and kinetic parameters within the control subject group., Interpretation: The identified kinematic changes can cause a shift in the normal load-bearing regions of the knee and may support the view that the risk of developing knee osteoarthritis in an anterior cruciate ligament ruptured joint while performing activities involving frequent landing and stopping actions is less likely to be associated with the knee adduction moment and is rather due to kinematic changes. Anterior cruciate ligament reconstruction surgery failed to restore normal knee kinematics during landing, potentially explaining the persistent risk for the development of knee osteoarthritis in patients who have returned to sports following reconstruction surgery., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The purpose of this article was to evaluate the risks and benefits of non-operative treatment versus surgical excision of a fabella causing posterolateral knee pain. We performed a systematic review of literature and also present two case reports.Twelve publications were found in a PubMed literature review searching the word "fabella syndrome". Non-operative treatment and surgical excision of the fabella has been described., Case Presentation: Two patients presented to our outpatient clinic with persisting posterolateral knee pain. In both cases the presence of a fabella was identified, located in close proximity to the posterolateral femoral condyle. All other common causes of intra- and extra articular pathologies possibly causing the posterolateral knee pain were excluded.Following failure to respond to physiotherapy both patients underwent arthroscopy which excluded other possible causes for posterolateral knee pain. The decision was made to undertake surgical excision of the fabella in both cases without complication.Both patients were examined 6 month and one year after surgery with the Tegner activity score, the Visual Analogue Scale (VAS), and International Knee Documentation Committee Score (IKDC)., Conclusion: Consistent posterolateral pain during exercise might indicate the presence of a fabella syndrome. Resecting the fabella can be indicated and is a minor surgical procedure with minimal risk. Despite good results in the literature posterolateral knee pain can persist and prevent return to a high level of sports., Level of Evidence: IV, case reports and analysis of literature.

A steadily growing number of empirical research on cyberbullying exists retaining the traditional definition of bullying. However, whether this scientific and theoretical definition represents youths' perceptions and experiences with cyberbullying is a subject of further investigation. Scenarios of cyberbullying incidents were used and later discussed in three focus groups with 20 adolescents (55 % boys, 45 % girls, 11-16 years old). Thematic and content analyses laid focus on the following questions: (1) Which terms are used by the adolescents to describe the behaviors in the incidents? (2) What are the roles of traditional bullying definition criteria (i. e. intention, repetition, and power imbalance) and two additional cyberbullying-specific criteria (i. e. anonymity and publicity)? (3) How are the behaviors perceived in comparison to each other? Results show that German adolescents perceive "cybermobbing" as the best term to describe the presented incidents. Impersonation was not perceived as cyberbullying by the adolescents, but rather viewed as a criminal act. In addition, adolescents perceived the intent to harm, the impact on the victim, and repetition relevant for defining cyberbullying. Moreover, analyses revealed an interdependence between criteria which suggests that anonymity and publicity have an effect on the severity of the behavior, however they were not essential for the definition of cyberbullying.

Introduction: Interference screw fixation of soft tissue grafts has been a widely used fixation technique for cruciate ligament reconstruction. Suturing of the graft construct prior to graft fixation has been proposed to increase fixation strength; however, the effect on mechanical properties has not been well characterized. The goal of this study was to determine whether uniform suturing of the tendon graft affects (1) ultimate fixation strength of the hamstring tendon graft and (2) motion of the tendon in the bone tunnel during cyclic loading when comparing sutured grafts vs. unsutured grafts., Method: Eight pairs of matched mature porcine tibias (age <2 years) and eight paired fresh-frozen human quadrupled hamstring tendon grafts were used. One quadrupled graft from each pair was placed into one of two groups. In the group A a single cerclage suture 3 cm from the doubled end of the graft was placed to join the four tendon strands. In group B a heavy suture was used to tightly unite the four strands of tendon graft to provide a better grip for the interference screw during fixation. The grafts were placed in tibial bone tunnels that matched the graft's diameter and fixed with an interference screw. The looped end of the graft and the attached tibia were rigidly fixed in a material testing machine. The graft constructs were subjected to 100 cycles of 20-250 N load, followed by a load-to-failure test. In addition, a motion analysis system was used during cyclic testing to better determine the amount of elongation at the graft-tunnel interface. Statistical analysis of the failure load and stiffness and the overall elongation following cyclical loading was performed using the Wilcoxon rank sum test. Level of significance was set at p < 0.05., Results: Elongation at the tendon-bone interface during sub-maximal cyclic loading was 2.4 ± 1.4 mm (unsutured) vs. 2.0 ± 0.7 mm (sutured) (p > 0.05). Failure load of the grafts without sutures (634 ± 86 N) was significantly lower than with the sutures (837 ± 183 N). Ultimate stiffness of group A (283 ± 34 N/mm) was lower than that of group B (331 ± 51 N/mm); however, this was not statistically significant (p = 0.051)., Conclusion: This study confirms that suturing of the graft construct before interference screw fixation may increase ultimate failure load. However, an improvement of structural properties in response to cyclic loading with sub-maximal loads could not be confirmed. Clinicians using interference screw fixation may suture the graft to improve fixation strength; however, suturing does not appear to allow a more aggressive rehabilitation after surgery.

Purpose: This longitudinal study aimed to examine whether patients with anterior cruciate ligament (ACL) reconstruction show a similar landing strategy during the single-leg hop test (SLHT) postsurgery analog to that previously identified when ACL deficient. It is hypothesized that ACL-reconstructed patients demonstrate greater trunk flexion to reduce knee joint moments at the cost of postural dynamic stability at their involved leg compared to their uninvolved leg., Methods: Ten ACL-reconstructed patients performed a bilateral SLHT 6 and 12 months after surgery. Landing mechanics were determined by means of a soft tissue artifact optimized, rigid, full-body model, and the margin of stability was quantified using an inverted pendulum approach. Knee extensor muscular strength (KS) was assessed during isometric maximal voluntary knee extension contractions., Results: ACL-reconstructed patients showed similar landing strategies as previously reported in their ACL-deficient state. By flexing their trunk, patients repositioned the ground reaction force vector more anteriorly in relation to the joints of the lower extremity (P < 0.05) and, in doing so, were able to transfer joint moments from the knee to the adjacent joints (P < 0.05). This upper body strategy reduced the margin of stability in the ACL-reconstructed leg during landing (P < 0.05). Twelve months after surgery, the ACL-reconstructed leg showed lower KS compared to the uninvolved leg (P < 0.05), and knee joint moment output during landing was significantly correlated to KS., Conclusions: The results highlight the important role of KS on the interaction between trunk angle, joint kinetics, and postural dynamic stability during landing and show that ACL-reconstructed patients use an analogous feedforward strategy (e.g., more flexed trunk) to that used in their ACL-deficient state, aiming to compensate for KS deficits and thereby sacrificing postural dynamic stability and increasing the risk of loss of balance during landing maneuvers.

The current study aimed to examine the effect of anterior cruciate ligament deficiency (ACLd) on joint kinetics and dynamic stability control after a single leg hop test (SLHT). Twelve unilateral ACLd patients and a control subject group (n=13) performed a SLHT over a given distance with both legs. The calculation of joint kinetics was done by means of a soft-tissue artifact optimized rigid full-body model. Margin of stability (MoS) was quantified by the difference between the base of support and the extrapolated center of mass. During landing, the ACLd leg showed lower external knee flexion moments but demonstrated higher moments at the ankle and hip compared to controls (p<0.05). The main reason for the joint moment redistribution in the ACLd leg was a more anterior position of the ground reaction force (GRF) vector, which affected the moment arms of the GRF acting about the joints (p<0.05). For the ACLd leg, trunk angle was more flexed over the entire landing phase compared to controls (p<0.05) and we found a significant correlation between moment arms at the knee joint and trunk angle (r² = 0.48;p<0.01). The consequence of this altered landing strategy in ACLd legs was a more anterior position of the center of mass reducing the MoS (p<0.05). The results illustrate the interaction between trunk angle, joint kinetics and dynamic stability during landing maneuvers and provide evidence of a feedforward adaptive adjustment in ACLd patients (i.e. more flexed trunk angle) aimed at reducing knee joint moments at the cost of dynamic stability control., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: Application of an arthroscopic suture system to restore the form and function of the meniscus by adaptation of a longitudinal tear close to the base., Indications: Unstable longitudinal tears near the base of the meniscus, mainly in the posterior horn of the medial or lateral of the meniscus. Dislocated bucket-handle tears of the medial and lateral meniscus close to the base., Contraindications: Poor tissue quality with fibrillated meniscal tissue. Meniscal tears in the avascular zone (zone I). Insufficient blood supply from the joint capsule and the base of the meniscus. Degenerative meniscal lesions. Anterior or posterior knee joint instability. Allergic reactions to nonresorbable suture material., Surgical Technique: Standard anterior arthroscopic portals. Arthroscopic assessment of the meniscal tear using the probe. Revitalization of the tear margins and perforation of the meniscal base to induce bleeding. Adaptation of the tear margins and fixation with a suture-anchor system using an ipsilateral standard portal for tears in the posterior horn or by way of a contralateral standard portal for tears in the lateral horn., Postoperative Management: Full weight bearing with the knee in extension in a knee immobilizer, relative to the pain threshold in the 1st postoperative week. Range of motion exercises without weight bearing from full extension to 90 degrees knee flexion (0/0/90). If simultaneous reconstruction of the anterior cruciate ligament (ACL) is being performed, rehabilitation protocols follow the principles for ACL reconstruction., Results: Since the year 2000, meniscal tears in more than 300 patients have been repaired with the all-inside suture system. In the context of a multicenter study by ESSKA (European Society for Sports Medicine, Surgery and Arthroscopy) involving 20 patients, the result was evaluated by direct MRI arthrography (gadolinium). The suture bar anchors were generally not detectable, the incision channels produced a hypodense signal in the meniscus tissue. If re-rupture occurred, it was because the meniscus had pulled out of the suture loop. Cartilaginous lesions were not found. There were no complications related to the nonresorbable suture bar anchors.

We report about the case of a 4(1/2)-year delayed screw fixation of a tibial posterior cruciate ligament (PCL) avulsion fracture in combination with a posterolateral stabilization. After open reduction and rigid screw fixation, combined with a posterolateral stabilization using a semitendinosus tendon autograft, the patient returned to full activity in sports and daily life. If the PCL substance is sufficient, a delayed refixation in an old PCL avulsion injury seems to be a viable alternative to PCL reconstruction.

Postoperative surgical site infections remain frequent despite intensive control programs. With rising numbers of operations and invasive procedures in the outpatient setting and in immunocompromised patients, the prevention of wound infections presents a rapidly growing challenge to the medical community. Barrier measures including drapes and surgical gowns to prevent wound contamination, have clearly reduced the rate of wound infections. The optimal material characteristics for operating gowns and drapes are well defined, but there is still a long running controversy on the use of single-use versus reusable materials. We review the efficacy and ecological impacts of these different approaches. Currently no superiority of any of these approaches with regard to either efficacy or ecological impact can be found. The European Union has recently published a series of mandatory standards to specify material characteristics of barrier materials used in operating theatres (EN 13795). Their scope include production standards of these materials as well as specific processes in auditing their characteristics. The implementation of these norms will clearly present a challenge to European hospitals but will lead to better material characteristics in the end.

The reconstruction of a ruptured anterior cruciate ligament (ACL) is a frequently performed operation, however technically demanding with a revision rate of approximately 10%. The correct placement of bone tunnels in femur and tibia is the most important variable to achieve a successful outcome. A distinct knowledge of the anatomic insertion sites is crucial. The ideal location for the femoral bone tunnel is achieved when a 1-2 mm posterior wall is left to the over-the-top position and when the entry to the bone tunnel is at 10 o'clock (right knees) or 14 o'clock (left knees) in the frontal plane. The femoral bone tunnel can be drilled through the tibial bone tunnel (transtibial technique) or through an anteromedial arthroscopic portal. According to recent studies the use of an anteromedial portal helps to reduce the risk of misplacement of the bone tunnel. The center of the tibial bone tunnel should be located on an imaginary line between medial border of the anterior horn of the lateral meniscus and the medial tibial spine. The position of the tibial guide wire has to be far enough posterior to avoid impingement of the graft with the roof of the intercondylar notch. Measures for quality control include the intraoperative use of an image intensifier (fluoroscopy), instrumented laxity measurements and a postoperative radiograph in 2 planes. The use of computer assisted surgery cannot routinely be recommended at present.

Several grafts and several fixation techniques have been introduced for PCL reconstruction over the past years. To date, autograft and allograft tissues are recommended for PCL reconstruction, whilst synthetic grafts should be avoided. Autograft tissues include the bone-patellar tendon-bone graft, the hamstrings and the quadriceps tendon. Allograft tissues are increasingly being used for primary PCL reconstruction. The use of allograft tissues requires a number of formal prerequisites to be fulfilled. Besides the previous mentioned graft types allograft tissues include Achilles and tibialis anterior/posterior tendons. To date no superior graft type has been identified. Several techniques and devices have been used for fixation of a PCL replacement graft. Most of these were originally developed for ACL reconstruction and then adapted to PCL reconstruction. However, biomechanical requirements of the PCL differ substantially from those of the ACL. To date, requirements for PCL graft fixations are not known. From a systematic approach femoral graft fixation can either be achieved within the bone tunnel (nearly anatomic) with an interference screw or outside the bone tunnel on the medial femoral condyle using a staple, an endobutton or a screw. Tibial graft fixation can be achieved either with an interference screw in the bone tunnel or with a staple, screw/washer or sutures tied over a bone bridge outside the bone tunnel (extra-anatomic). An alternative fixation on the tibial side is the inlay technique that reduces the acute angulation of the graft at the posterior aspect of the tibia. Further research is necessary to identify the differences between the various fixation techniques.

After replacement of the anterior cruciate ligament with a free tendon graft, the substitute initially is avascular and without a synovial surface. To ensure long-term survival, the graft must become revascularized. Despite numerous studies on the topic, there still is discussion regarding revascularization. The goal of the current study was to investigate the endoligamentous microcapillary revascularization of the free tendon graft after anterior cruciate ligament replacement with time. Thirty-six mature sheep had an anterior cruciate ligament reconstruction with an ipsilateral flexor tendon split graft. Midsubstance tissue samples were immunostained for von Willebrand factor (Factor VIII) at 6, 9, 12, 24, 52, and 104 weeks to detect the endothelial cells of capillaries. Cross sections of vessels were determined in three zones (subsynovial, intermediate, and center of the graft) and were evaluated by means of histomorphometry using a digital imaging analysis system. The observations showed that capillary vessels, which originate from the synovial envelope, invaded the avascular graft tissue from the surface toward the center zone. The highest level of vascular density was found after 6 weeks, reaching the vascular status of the native anterior cruciate ligament after 24 weeks. These findings are in contrast to the findings of previous studies in animals. The current study showed, for the first time, the kinetics of an endoligamentous revascularization of a free tendon graft at the capillary level. In the current model, the process of revascularization terminated earlier than previously described.

Purpose: To evaluate the diagnostic impact of different CT-based measurements to analyze the patellofemoral alignment after arthroscopic reconstruction in patients with patella dislocation., Materials and Methods: In 18 patients with dislocation of the patella, CT of the patellofemoral joint was performed after arthroscopic reconstruction. Various methods recommended in the literature were used to analyze the structure and the alignment of the patellofemoral joint with a relaxed quadriceps muscle. Axial CT scans were taken in four different knee flexion angles (15 degrees, 30 degrees, 45 degrees, 60 degrees )., Results: After arthroscopic stabilization in patients with patella dislocation, only the lateral patellofemoral angle (15 degrees and 30 degrees knee flexion) and the congruence angle (15 degrees knee flexion) showed significant differences between the CT-measurements in the normal and the operated group. The differences of the remaining mean values were not significant due to a high standard deviation. With increasing flexion of the knee, the differences between the normal and the dislocation group almost disappeared. Only the lateral patellofemoral angle, the patella tilt and the lateral patella shift revealed differences between the normal and the group with recurrent dislocation in every degree of knee flexion. With increasing knee flexion above 30 degrees and especially at 60 degrees, the majority of the measured values returned to the normal range., Conclusions: For CT-measurements of the patellofemoral joint after arthroscopic stabilization, the patellofemoral angle and the congruence angle seemed to be most useful. The measurements of the patellofemoral joint should be taken in various degrees of knee flexion.

Various graft choices have evolved over the past few decades for the primary reconstruction of the anterior cruciate ligament (ACL). Three predominant autologous graft choices exist today: patellar, hamstring, and quadriceps tendons. Clinical studies have as yet failed to demonstrate significant differences in clinical outcome among these grafts, irrespective of their varying fixation techniques. Therefore, other factors such as graft harvest morbidity have become more important when comparing different grafts. These factors can differ substantially between the grafts, depending on the type of patients' activities, the injury pattern, and the associated injuries of the knee joint. A basic knowledge of these factors and the parameters that affect the mechanical and biological behavior of the reconstructed ACL can help to find the appropriate graft choice for each individual patient. Factors such as harvest site morbidity, fixation techniques, osseous integration, and tunnel widening are discussed based on current clinical and basic science studies. Finally, an outlook is given for future alternatives with evolving techniques for tissue-engineered grafts, allografts, or the transplantation of xenogeneic donor tissue.

A new method is presented to quantify the extent of posterolateral knee laxity. Stress computed tomography (CT) is performed to determine external rotation of the tibia on both knees. Manual maximum external torque is applied to the tibia from both feet by an examiner while both femurs are stabilized by a tape at approximately 30 degree of knee flexion. CT images are acquired at this position and side-to-side differences of external rotation are determined from the images by standard computer software. The technique is simple and helps to quantify posterolateral knee laxity before and after surgical procedures of posterolateral knee reconstruction.

Ten cadaveric knees (donor ages, 36 to 66 years) were tested at full extension, 15 degrees, 30 degrees, and 90 degrees of flexion under a 134-N anterior tibial load. In each knee, the kinematics as well as in situ force in the graft were compared when the graft was fixed with the tibia in four different positions: full knee extension while the surgeon applied a posterior tibial load (Position 1), 30 degrees of flexion with the tibia at the neutral position of the intact knee (Position 2), 30 degrees of flexion with a 67-N posterior tibial load (Position 3), and 30 degrees of flexion with a 134-N posterior tibial load (Position 4). For Positions 1 and 2, the anterior tibial translation and the in situ forces were up to 60% greater and 36% smaller, respectively, than that of the intact knee. For Position 3, knee kinematics and in situ forces were closest to those observed in the intact knee. For Position 4, anterior tibial translation was significantly decreased by up to 2 mm and the in situ force increased up to 31 N. These results suggest that the position of the tibia during graft fixation is an important consideration for the biomechanical performance of an anterior cruciate ligament-reconstructed knee.

Suture techniques are the standard for fixation of meniscus bucket-handle lesions. In 1993 a new method for meniscus repair with self-reinforced biodegradable "arrows" was introduced. Currently, various meniscus implants are available in Germany and are widely used clinically. The purpose of this paper was to evaluate and discuss the literature on biodegradable meniscus implants. Relevant articles were retrieved from Medline of the National Library of Medicine (1966 until July 2000) using the combined search strategy for the keywords "meniscal repair" and "arrow." Ten publications were found. The reported advantages of meniscus arrows are the reduced operation time, the easy surgical technique, and the reduced risk of neurovascular injury. In most experimental studies, lower failure strength of meniscus arrows was found compared to meniscus sutures. In clinical studies, the meniscal healing rates comparing the arrow technique and suture technique are comparable. Various complications of the new arrow technique have been reported such as inflammatory foreign-body reaction, cartilage lesions, and arrow displacement. Based on the existing literature, no final judgment is possible. Currently, individual indications depending on the kind of meniscal lesion and location are recommended. A combination of suture and arrow technique might be a treatment option, but further prospective randomized studies and longer follow-ups are necessary.

Over the past century numerous graft materials have been used for the reconstruction of the cruciate ligament of the knee. Among the autologous tissues that are currently recommended as graft materials, the central bone patellar tendon bone graft, a quadrupled hamstring graft and the central quadriceps tendon graft have the greatest clinical significance. With some limitations, allograft materials can also be used. Each of the three mentioned grafts has specific features regarding morphological and structural properties, graft fixation and graft incorporation. Clinical studies have failed to identify any of the three grafts as superior to the others. When choosing the graft for surgery the different anatomy and function of the anterior and posterior cruciate ligaments have to be considered. For the treatment of multiple ligament injuries and for revision cases, thorough preoperative planning is necessary and modified graft selection may be required.

We compared the mechanical behavior of two common hamstring graft constructs that are frequently used for reconstruction of the anterior cruciate ligament-Graft A: quadrupled semitendinosus tendon fixed with titanium button/polyester tape and suture/screw post, and Graft B: a double semitendinosus and double gracilis tendon fixed with a cross pin and two screws over washers. The experimental protocol used to evaluate each graft construct included stress relaxation (with and without preconditioning), cyclic loading, and a tensile load-to-failure test. The amount of stress relaxation without preconditioning was 60.6% for Graft A and 53.8% for Graft B. With preconditioning, it significantly decreased (p < 0.05) to 48.7 and 42.3%, respectively. Elongation of the graft construct in response to 100 cycles of loading (20-150 N) was 1.8 and 0.6% of the original length for Grafts A and B, respectively. However, after a series of five cyclic loading tests, the residual permanent elongation for each construct was 3.8 +/- 1.2 and 0.3 +/- 0.2 mm, a significant difference (p < 0.05) between the two graft constructs. Further analysis found more than 90% of the permanent elongation in the proximal and distal regions of Graft A, which consisted of polyester tape tied to a titanium button (proximal) and sutures tied around a screw post (distal). The tensile load-to-failure tests also revealed significant differences (p < 0.05) between the two graft constructs. Linear stiffness was 32 +/- 1 and 119 +/- 19 Nmm and ultimate load was 415 +/- 36 and 658 +/- 128 N for Grafts A and B, respectively. For Graft A, the polyester tape consistently failed; for Graft B, slippage or tearing from the washers was the mode of failure. We conclude that a quadruple-hamstring graft fixed over a cross pin proximally and with metal washers distally (Graft B) has less permanent elongation in response to cyclic loading and has structural properties superior to those of a graft construct that includes suture and tape material (Graft A). The large permanent elongation following repetitive loading of a graft construct with tape and suture material during the early postoperative period is of concern.

The objective of this study was to determine the effects of sectioning the posterolateral structures (PLS) on knee kinematics and in situ forces in the posterior cruciate ligament (PCL) in response to external and simulated muscle loads. Ten human cadaveric knees were tested using a robotic/universal force-moment sensor testing system. The knees were subjected to three loading conditions: (a) 134-N posterior tibial load, (b) 5-Nm external tibial torque, and (c) isolated hamstring load (40 N biceps/40 N semimembranosus). The knee kinematics and in situ forces in the PCL for the intact and PLS-deficient knee conditions were determined at full extension, 30 degrees, 60 degrees, 90 degrees, and 120 degrees of knee flexion. Under posterior tibial loading posterior tibial translation with PLS deficiency increased significantly at all flexion angles by 5.5+/-1.5 mm to 0.8+/-1.2 mm at full extension and 90 degrees, respectively. The corresponding in situ forces in the PCL increased by 17-19 N at full extension and 30 degrees of knee flexion. Under the external tibial torque, external tibial rotation increased significantly with PLS deficiency by 15.1+/-1.6 degrees at 30 degrees of flexion to 7.7+/-3.5 degrees at 90 degrees, with the in situ forces in the PCL increasing by 15-90 N. The largest increase occurred at 60 degrees to 120 degrees of knee flexion, representing forces two to six times of those in the intact knee. Under the simulated hamstring load, posterior tibial translation and external tibial and varus rotations also increased significantly at all knee flexion angles with PLS deficiency, but this was not so for the in situ forces in the PCL. Our data suggest that injuries to the PLS put the PCL and other soft tissue structures at increased risk of injury due to increased knee motion and the elevated in situ forces in the PCL.

We hypothesized that posterior cruciate ligament reconstructions are often compromised by associated injuries to the posterolateral structures. Therefore, we evaluated a posterior cruciate ligament reconstruction in isolated and combined injury models using a robotic/universal force-moment sensor testing system. The resulting knee kinematics and the in situ forces in the native and reconstructed posterior cruciate ligament were determined under four external loading conditions. In the isolated injury model, reconstruction reduced posterior tibial translation to within 1.5+/-1.3 to 2.4+/-1.4 mm of the intact knee at 30 degrees and 90 degrees under a 134-N posterior tibial load. In the combined injury model, deficiency of the posterolateral structures increased posterior tibial translation of the reconstructed knee by 6.0+/-2.7 mm at 30 degrees and 4.6+/-1.5 mm at 90 degrees of flexion. External rotation increased up to 14 degrees while varus rotation increased up to 7 degrees. In situ forces in the posterior cruciate ligament graft also increased significantly (by 22% to 150%) for all loading conditions. Our results demonstrate that a graft that restores knee kinematics for an isolated posterior cruciate ligament deficiency is rendered ineffective and may be overloaded if the posterolateral structures are deficient. Therefore, surgical reconstruction of both structures is recommended in the setting of a combined injury.

The objectives of this study were to determine the effects of hamstrings and quadriceps muscle loads on knee kinematics and in situ forces in the posterior cruciate ligament of the knee and to evaluate how the effects of these muscle loads change with knee flexion. Nine human cadaveric knees were studied with a robotic manipulator/universal force-moment sensor testing system. The knees were subjected to an isolated hamstrings load (40 N to both the biceps and the semimembranosus), a combined hamstrings and quadriceps load (the hamstrings load and a 200-N quadriceps load), and an isolated quadriceps load of 200 N. Each load was applied with the knee at full extension and at 30, 60, 90, and 120 degrees of flexion. Without muscle loads, in situ forces in the posterior cruciate ligament were small, ranging from 6+/-5 N at 30 degrees of flexion to 15+/-3 N at 90 degrees. Under an isolated hamstrings load, the in situ force in the posterior cruciate ligament increased significantly throughout all angles of knee flexion, from 13+/-6 N at full extension to 86+/-19 N at 90 degrees. A posterior tibial translation ranging from 1.3+/-0.6 to 2.5+/-0.5 mm was also observed from full extension to 30 degrees of flexion under the hamstrings load. With a combined hamstrings and quadriceps load, tibial translation was 2.2+/-0.7 mm posteriorly at 120 degrees of flexion ut was as high as 4.6+/-1.7 mm anteriorly at 30 degrees. The in situ force in the posterior cruciate ligament decreased significantly under this loading condition compared with under an isolated hamstrings load, ranging from 6+/-7 to 58+/-13 N from 30 to 120 degrees of flexion. With an isolated quadriceps load of 200 N, the in situ forces in the posterior cruciate ligament ranged from 4+/-3 N at 60 degrees of flexion to 34+/-12 N at 120 degrees. Our findings support the notion that, compared with an isolated hamstrings load, combined hamstrings and quadriceps loads significantly reduce the in situ force in the posterior cruciate ligament. These data are in direct contrast to those for the anterior cruciate ligament. Furthermore, we have demonstrated that the effects of muscle loads depend significantly on the angle of knee flexion.

The objective of this study was to determine the relative motion of a quadruple hamstring graft within the femoral bone tunnel (graft-tunnel motion) under tensile loading. Six graft constructs were prepared from the semitendinosus and gracilis tendons of human cadavers and were fixed with a titanium button and polyester tape within a bone tunnel in a cadaveric femur. Three different lengths of polyester tape (15, 25, and 35 mm loops) were evaluated. The femur was held stationary and uniaxial tensile loads were applied to the distal end of the graft using a materials testing machine. Each construct was subjected to loading for ten cycles with upper limits of 50 N, 100 N, 200 N and 300 N. Graft-tunnel motion was then determined using the distances between reflective tape markers placed on the hamstring graft and at the entrance to the femoral bone tunnel, which were tracked with a high-resolution video system. Graft-tunnel motion was found to range from 0.7 +/- 0.2 mm to 3.3 +/- 0.2 mm, and significant increases in graft-tunnel motion were observed with increasing tensile loads (P < 0.05). Shorter tape length (15 mm) resulted in significantly less motion when compared to longer tape length (35 mm) (P < 0.05). We conclude that graft-tunnel motion is significant and should be considered when using this fixation technique. Early stress on the graft, as seen in postoperative rehabilitation exercises and athletic activities, may cause large graft-tunnel motion before graft incorporation is complete. A shorter distance between the tendon tissue and the titanium button is recommended to minimize the amount of graft-tunnel motion. Alternative fixation materials to polyester tape, or different fixation techniques, need to be developed such that graft-tunnel motion can be reduced. Further studies are needed to evaluate the effect of graft-tunnel motion on graft incorporation in the bone tunnel.

The posterolateral structures of the knee consist of a complex anatomical architecture that includes several components with both static and dynamic functions. Injuries of the posterolateral structures occur frequently in conjunction with ruptures of the posterior cruciate ligament. To investigate the role of the posterolateral structures in maintaining posterior knee stability, we measured the in situ forces in the posterolateral structures and the distribution of force within the structures' major components, i.e., the popliteus complex and the lateral collateral ligament, in response to a posterior tibial load. Eight cadaveric knees were tested. With use of a robotic/universal force-moment sensor testing system, a posterior tibial load of 110 N was applied to the knee, and the resulting five-degree-of-freedom kinematics were measured at flexion angles of 0, 30, 60, 75, and 90 degrees. The knees were tested first in the intact state and then after the posterior cruciate ligament had been resected. These tests were also performed with an additional load of 44 N applied at the aponeurosis to simulate contraction of the popliteus muscle. In the intact knee, the in situ forces in the posterolateral structures were found to decrease with increasing knee flexion. After the posterior cruciate ligament was sectioned, these forces increased significantly at all angles of flexion. With no load applied to the popliteus muscle, the in situ forces in the popliteus complex were similar to those in the lateral collateral ligament. However, with a load of 44 N applied to the popliteus muscle, in situ forces in the popliteus complex were three to five times higher than those in the lateral collateral ligament. These results reveal that in response to posterior tibial loads, the posterolateral structures play an important role at full extension in intact knees and at all angles of flexion in posterior cruciate ligament-deficient knees. The popliteus muscle appears to be a major stabilizer under this loading condition; thus, the inability to restore its function may be a cause of unsatisfactory results in reconstructive procedures of the posterolateral structures of the knee.

To investigate the effect of simulated contraction of the popliteus muscle on the in situ forces in the posterior cruciate ligament and on changes in knee kinematics, we studied 10 human cadaveric knees (donor age, 58 to 89 years) using a robotic manipulator/universal force moment sensor system. Under a 110-N posterior tibial load (simulated posterior drawer test), the kinematics of the intact knee and the in situ forces in the ligament were determined. The test was repeated with the addition of a 44-N load to the popliteus muscle. The posterior cruciate ligament was then sectioned and the knee was subjected to the same tests. The additional popliteus muscle load significantly reduced the in situ forces in the ligament by 9% to 36% at 90 degrees and 30 degrees of flexion, respectively. No significant effects on posterior tibial translation of the intact knee were found. However, in the ligament-deficient knee, posterior tibial translation was reduced by up to 36% of the translation caused by ligament transection. A coupled internal tibial rotation of 2 degrees to 4 degrees at 60 degrees to 90 degrees of knee flexion was observed in both the intact and ligament-deficient knees when the popliteus muscle load was added. Our results indicate that the popliteus muscle shares the function of the posterior cruciate ligament in resisting posterior tibial loads and can contribute to knee stability when the ligament is absent.

Improved basic science data on the anatomy and biomechanics of the human posterior cruciate ligament have provided the orthopaedic surgeon with new information on which to base treatment decisions. Injuries to the posterior cruciate ligament are reported to comprise approximately 3% of all knee ligament injuries in the general population and as high as 37% in an emergency department setting. While the diagnosis of a posterior cruciate ligament injury can often be made with a physical examination, ancillary studies such as radiographs and magnetic resonance images can be very helpful in detecting associated ligament and bony injuries. In general, most partial (grades I and II) posterior cruciate ligament injuries can be treated nonoperatively. However, surgical reconstruction is usually recommended for those posterior cruciate ligament injuries that occur in combination with other structures. In this review, current surgical techniques of posterior cruciate ligament reconstruction based on anatomic and biomechanical studies will be discussed.

Radiographic enlargement of bone tunnels following anterior cruciate ligament (ACL) reconstruction has been recently introduced in the literature; however, the etiology and clinical relevance of this phenomenon remain unclear. While early reports suggested that bone tunnel enlargement is mainly the result of an immune response to allograft tissue, more recent studies imply that other biological as well as mechanical factors play a more important role. Biological factors associated with tunnel enlargement include foreign-body immune response (against allografts), non-specific inflammatory response (as in osteolysis around total joint implants), cell necrosis due to toxic products in the tunnel (ethylene oxide, metal), and heat necrosis as a response to drilling (natural course). Mechanical factors contributing to tunnel enlargement include stress deprivation of bone within the tunnel wall, graft-tunnel motion, improper tunnel placement, and aggressive rehabilitation. Graft-tunnel motion refers to longitudinal and transverse motion of the graft within the bone tunnel and can occur with various graft types and fixation techniques. Aggressive rehabilitation programmes may contribute to tunnel enlargement as the graft-bone interface is subjected to early stress before biological incorporation is complete. Further basic research is required to verify the effect of the various proposed factors on the etiology of bone tunnel enlargement. We recommend that routine follow-up examinations after ACL reconstruction should include the measurement of bone tunnel size in order to contribute to a better understanding of the incidence, time course, and clinical relevance of this phenomenon. Improved and more anatomical surgical fixation techniques may be useful for the prevention of bone tunnel enlargement.

Our objective was to compare the effect of two methods of data collection on results in a functional knee score. Two Lysholm scores were obtained for 61 patients 1 year after anterior cruciate ligament surgery at the same clinic visit. First, the patients completed a self-administered questionnaire, and second, the Lysholm score form was completed by the investigator in the course of a patient interview. A comparison of the scores revealed that the mean score was significantly lower with self-administration (self, 89.3 +/- 10.6; interviewer, 92.2 +/- 7.4) (P = 0.0035, Wilcoxon rank sum test). The assignment to one of four categories (excellent, good, fair, poor) was also significantly altered by the manner of data collection. Nineteen patients (31%) were assigned to different categories based on the mode of data collection. We believe that the major reason for a better score result with an interview was the presence of interview bias. The more the investigator is involved in the treatment of the patient, the greater the influence of this bias may be. To avoid such potential bias we suggest that a standardized self-administered questionnaire be used as the method of choice for obtaining subjective data in clinical settings.

In a double-blind, randomized trial, 40 patients undergoing open anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft were randomly allocated to two groups: group A (n = 20) received an intra-articular instillation of 20 mL bupivacaine (0.25%) and a local infiltration of 20 mL bupivacaine (0.5%) 15 minutes before surgery. Group B (n = 20) received an injection of saline solution in the same manner. Patient-controlled on-demand analgesia (PCA) with intravenous piritramid was used for postoperative pain control. A significant decrease in pain scores on a visual analog scale (VAS scale, 0 to 10) was found in the bupivacaine group (group A) at bedrest on the day of surgery only (pain score, 5.5 v 7.3 (scale, 0 to 10), P < .05). At all other times, no significant differences were found. The overall supplemental opioid requirements were not different between the study groups (63.9 v 62.6 mg piritramid/72 hours). A long-lasting, clinically relevant, pain-reducing effect with infiltration of bupivacaine before surgery could not be shown with this study.

Patients' complaints on limitations in activities of daily living (ADL) and sports are possible signs for various injuries of the knee joint. These complaints can be easily assessed by the patient using a questionnaire with visual analogue scale (VAS) responses. A German translation of the English questionnaire concerning knee complaints [4] has been validated and tested for clinical use. It consists of 28 questions. For the statistical analysis, an overall score (VAS score) of the questionnaire was determined. The validation included an expert evaluation on the content of the questionnaire, a test for the reliability, a comparison with subjective knee scoring systems (Cincinnati score, Lysholm score) and a test on VAS score results in patient groups with various knee injuries (discrimination of patients). For the evaluation of operative treatment results, the responsiveness of the questionnaire was tested in patients undergoing arthroscopic meniscus surgery and anterior cruciate ligament reconstruction. The investigation was conducted prior to the operation, 2, 6, 12 and 24 weeks after surgery for both groups and also 36 weeks after surgery for the cruciate ligament patients. Interviews conducted with knee surgeons (so-called knee experts) revealed that 85% judged the questionnaire as being acceptable for clinical use. The reliability of the VAS score for healthy individuals was r = 0.86. The reliability for patients in a postoperative rehabilitation programme was r = 0.92. By means of the VAS score we were able to assess the extent of limitations in knee function in various patient groups with meniscus lesions, insufficiency ot the anterior and posterior cruciate ligaments and chondromalacia.(ABSTRACT TRUNCATED AT 250 WORDS)

The ankle sprain is one of the most common injuries in sports. It is useful to classify the grade of injury clinically. Stress x-rays, stress ultrasound or radiographic examinations are not necessary. Based on the analysis of 24 controlled studies we conclude that functional treatment is sufficient. It does not lead to higher subjective or objective instability nor to a greater number of reinjuries. Functional treatment has no complications. Although controlled studies about the treatment of athletes are missing, but there is no reason for a different treatment in athletes.

This retrospective study compares the results of different therapies for fibular ligament rupture in a homogenous group of professional athletes. The endpoint "competitive sports" was an outcome consideration. Subjects were examined by means of a standardized questionnaire and a structured interview. One hundred and seventy-nine of the questionnaires were completed and returned for evaluation. All of the basketball players with severe ankle sprain (supination trauma with swelling, pain, and inability to bear stress) were included. Those players with fractures of the foot, pronation trauma, or additional distal fibula or tibia fractures were excluded from this study. Of the 179 basketball players 160 (89%) had suffered severe ankle sprain. The treatment was divided into three groups: primary surgery (N = 35), plaster cast (N = 39), and functional treatment (N = 89). While simple ligament injuries (Grade I and II) were mostly treated functionally, complex ligament injuries (Grade III) were usually operated on. A total of 119 (74%) of the players reported no further pain. For pain reduction surgical and functional treatments showed advantages over plaster treatment. In the surgical group 63% of the players judged their regained stability to be equivalent to that of their healthy leg. Only 50% of the players in the plaster and functional groups believed their ankle joints to have regained the same stability as before their injuries. Despite the achievement of good results through surgery, there were clear differences in the players' assessments of their performance in competitive sports. Most subjects (92%) did not have any problems in everyday life regardless of which kind of therapy had been chosen.(ABSTRACT TRUNCATED AT 250 WORDS)