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The long-term results over 20 years following meniscal repair in stable knees have not been described yet. The objective was therefore to analyze the clinical and radiological outcomes of successful, isolated, open meniscal repairs with an intact ACL after a mean follow-up of 20.6 years (range, 16-25) retrospectively in 26 patients. Clinical evaluation included objective (Lysholm, IKDC, Tegner) and subjective scores. Standard radiological assessment according to Ahlbäck's osteoarthritis classification and weight-bearing full-leg radiography for alignment were performed. Eight patients were excluded due to a re-rupture of the meniscus. In the 18 remaining patients (12 male, 6 female), the mean Lysholm and IKDC score was 97.8 points (range, 85-100) and 93% (range, 77-100) at the most recent follow-up, respectively. The Tegner activity scale averaged 4.2 (range, 3-7). Subjectively, 13 patients rated their outcome excellent, 4 good, and 1 fair. The radiological evaluation demonstrated an average development of "+1" grade (range, 0-"+2") osteoarthritic changes versus preoperatively; however, the contralateral healthy knee also revealed comparable (on average "+1" grade) degenerative changes reflecting natural history. The alignment was not significantly different between the operated and the contralateral leg. Overall, isolated open meniscal repair in stableness has the potential of a successful surgery with good to excellent long-term results. The development of osteoarthritic changes within the femorotibial compartments is mild and comparable to contralateral and the alignment of the axis is preserved. Therefore, repair of a ruptured meniscus is recommended whenever possible, even in isolated meniscal tears. However, a re-rupture rate of approximately 30% in isolated meniscal tears has to be acknowledged, which still reflects the need for biological enhancement of meniscal healing. [ABSTRACT FROM AUTHOR]

BACKGROUND: In anterior cruciate ligament (ACL) reconstruction using hamstring grafts, the graft can be looped, resulting in an increased graft diameter but reducing graft length within the tunnels. HYPOTHESIS: After 6 and 12 weeks, structural properties and knee kinematics after soft tissue ACL reconstruction with 15 mm within the femoral tunnel will be significantly inferior when compared with the properties of ACL reconstruction with 25 mm in the tunnel. STUDY DESIGN: Controlled laboratory study. METHODS: In an intra-articular goat model, 36 ACL reconstructions using an Achilles tendon split graft were performed with 15-mm (18 knees) and 25-mm (18 knees) graft length in the femoral tunnel. Animals were sacrificed 6 weeks and 12 weeks after surgery and knee kinematics was tested. In situ forces as well as the structural properties were determined and compared with those in an intact control group. Histologic analyses were performed in 2 animals in each group 6 and 12 weeks postoperatively. Statistical analysis was performed using a 2-factor analysis of variance test. RESULTS: Anterior cruciate ligament reconstructions with 15 mm resulted in significantly less anterior tibial translation after 6 weeks (P < .05) but not after 12 weeks. Kinematics after 12 weeks and in situ forces of the replacement grafts at both time points showed no statistically significant differences. Stiffness, ultimate failure load, and ultimate stress revealed no statistically significant differences between the 15-mm group and the 25-mm group. CONCLUSION: The results suggest that there is no negative correlation between short graft length (15 mm) in the femoral tunnel and the resulting knee kinematics and structural properties. CLINICAL RELEVANCE: Various clinical scenarios exist in which the length of available graft that could be pulled into the bone tunnel (femoral or tibial) could be in question. To address this concern, this study showed that reducing the tendon graft length in the femoral bone tunnel from 25 mm to 15 mm did not have adverse affects in a goat model. [ABSTRACT FROM AUTHOR]

To date, the intraarticular rupture pattern of the anterior cruciate ligament (ACL) has not been reported. The ACL is a complex structure consisting of two functionally synergistic structures: the anteromedial (AM) and posterolateral (PL) bundle. The purpose of our study was to evaluate the intraarticular rupture pattern of the ACL with regard to its two functional bundles. We examined ACL rupture patterns with regard to the integrity of AM and PL bundle in 121 consecutive patients undergoing anterior cruciate ligament reconstruction surgery within 120 days after injury. The intraarticular pattern was observed by one experienced surgeon. In 25% of the patients a partial rupture of the ACL was found, whereas in the remaining 75% a complete rupture of AM and PL bundles was seen. A partial rupture could only be detected by careful dissection of the ligament. In 44% of all patients the AM and PL bundles did not rupture at the same location. In 12% of the patients the PL bundle showed no signs of rupture. When performing ACL reconstruction, care should be taken when dissecting down the ACL remnants to evaluate intact fiber bundles of the ACL. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether oxygen-dependent activation patterns of hypoxia-inducible factor 1alpha (HIF-1alpha) observed in vascularized tissues are conserved within avascular and hypoxic articular cartilage and whether HIF-1alpha affects cartilage matrix synthesis. METHODS: Explants of bovine articular cartilage and primary chondrocytes were exposed to normoxia (21% O2), hypoxia (2% O2), and simulated hypoxia (21% O2 plus CoCl2). Western blot and immunofluorescence analyses of HIF-1alpha were performed to determine HIF-1alpha activation patterns. To simulate cartilage loss from disease or injury, the top layers of cartilage were removed from osteochondral explants, and the residual cartilage was assessed for HIF-1alpha immunolocalization and proteoglycan synthesis. RESULTS: We demonstrated continuous nuclear translocation of HIF-1alpha in deeper layers of intact articular cartilage. HIF-1alpha was not completely degraded in chondrocytes exposed to normoxia, but rather, colocalized to the Golgi complex, a finding not previously reported for any cell type. Following alteration of the oxygen gradient by removal of the top layers of cartilage, predominantly perinuclear HIF-1alpha was found in the deeper layers. Restoration of intranuclear HIF-1alpha to these areas was achieved by hypoxia and simulated hypoxia. Under conditions in which HIF-1alpha was inactivated, matrix synthetic activity was altered (P < 0.0001) compared with control cartilage. CONCLUSION: These findings demonstrate that hypoxia-dependent activation of HIF-1alpha is highly conserved and that changes in oxygen tensions following cartilage loss from injury or disease alter cartilage metabolism in part by changing HIF-1alpha activity. The discovery of tonic activation of HIF-1alpha within intact articular cartilage underscores its potential importance to cartilage homeostasis. [ABSTRACT FROM AUTHOR]

The first follow-up treatment recommendation from the DGOU's Clinical Tissue Regeneration working group dates back to 2012. New scientific evidence and changed framework conditions made it necessary to update the follow-up treatment recommendations after cartilage therapy.As part of a multi-stage member survey, a consensus was reached which, together with the scientific evidence, provides the basis for the present follow-up treatment recommendation.The decisive criterion for follow-up treatment is still the defect localisation. A distinction is made between femorotibial and patellofemoral defects. In addition, further criteria regarding cartilage defects are now also taken into account (stable cartilage edge, location outside the main stress zone) and the different methods of cartilage therapy (e. g. osteochondral transplantation, minced cartilage) are discussed.The present updated recommendation includes different aspects of follow-up treatment, starting with early perioperative management through to sports clearance and resumption of contact sports after cartilage therapy has taken place., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: Many studies have investigated the relationship between muscle activation and tensile force of the anterior cruciate ligament. These studies lacked a holistic representation of the muscle status. For instance, they were limited with respect to the peak muscle forces, number of muscles, and possible muscle activation patterns., Design: This study used a knee surrogate including ten muscles with motor-controlled muscle force activation crossing the knee joint, thus providing a fully muscle-supported knee joint., Methods: Anterior cruciate ligament tensile force is measured in different knee flexion and extension movements to evaluate ratios of quadriceps/hamstring muscle activations in low hip angle setups., Results: Increasing the extension of the leg increased anterior cruciate ligament tension forces. Different quadriceps/hamstring ratios had different effects on anterior cruciate ligament tension forces during unrestricted flexion and extension movements. This was dependent on the direction of movement. Sole hamstring activation increased the anterior cruciate ligament tensile forces in extension movements compared with flexion movements. Sole quadriceps activation provoked greater anterior cruciate ligament tensile forces in flexion than in extension. This was not prominent in the test in which the other muscle groups counteracted the dominant muscle group., Conclusions: The findings from the present study demonstrate that active hamstring activation can reduce the load on the anterior cruciate ligament, and the dominant quadriceps increase anterior cruciate ligament loads for knee flexions of less than 40°. Moreover, the anterior cruciate ligament is loaded differently in flexion or extension movements with flexion movements, resulting in higher anterior cruciate ligament loads., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To evaluate whether a sandwich technique procedure for large osteochondral lesions (OCL) of the medial femur condyle reduces clinical symptoms and improves activity level as well as to assess repair tissue integration on MRI over 2 years., Design: Twenty-one patients (median age: 29 years, 18-44 years) who received matrix-associated autologous chondrocyte transplantation (MACT) combined with cancellous bone grafting at the medial femur condyle in a 1-step procedure were prospectively included. Patients were evaluated before surgery (baseline) as well as 3, 6, 12, and 24 months postoperatively, including clinical evaluation, Lysholm score, Tegner Activity Rating Scale, and MRI with Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and a modified Whole-Organ Magnetic Resonance Imaging Score (WORMS)., Results: Seventeen patients were available for the 24-month (final) follow-up (4 dropouts). Lysholm significantly improved from 48 preoperatively stepwise to 95 at final follow-up ( P < 0.05). Tegner improvement from 2.5 at baseline to 4.0 at final follow-up was not significant ( P = 1.0). MOCART score improved significantly and stepwise from 65 at 3 months to 90 at 24 months ( P < 0.05). Total WORMS improved from 14.5 at surgery to 7.0 after 24 months ( P < 0.05). Body mass index and defect size at surgery correlated with total WORMS at final follow-up ( P < 0.05) but did not correlate with clinical scores or defect filling., Conclusion: MACT combined with cancellous bone grafting at the medial femoral condyle reduces symptoms continuously over 2 years. A 1-step procedure may reduce perioperative morbidity. However, despite improvements, patients' activity levels remain low, even 2 years after surgery.

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Competing Interests: Alle Autoren sind aktive Mitglieder der Gesellschaft für Orthopädisch-Traumatologische Sportmedizin e.V. (GOTS) und für die Fachgesellschaft in ehrenamtlicher Funktion im Vorstand bzw. im Komitee „Prävention“ tätig.

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Purpose: It remains unclear if morphologic patterns of the patella itself predispose to patellar instability. This study examined established patellar landmarks in relation to the femoral condyle width to clarify differences of patellar morphologies in patellofemoral stable and unstable patients., Methods: Magnetic Resonance Imaging of 50 subjects (20.7 ± 4.4 years; 17 males, 33 females) with patellofemoral instability (study group, SG) and 50 subjects (25.3 ± 5.8 years; 31 males, 19 females) with anterior cruciate ligament rupture (control group, CG) were analyzed. Corresponding patellar value indices (PW-I; LPF-I 1; LPF-I 2) in relation to the femoral condyle width (FCW) were evaluated after the measurement of absolute patellar dimension [patellar width (PW); direct length of the lateral patellar facet (LPF-1); projected length of the lateral patellar facet (LPF-2)]. The patellar shape according to Wiberg, trochlear dysplasia, patellar height, and tibial tubercle-trochlear groove (TT-TG) distance were determined., Results: The SG showed a significantly longer absolute (LPF 2) (P = 0.041) and relative (LPF-I 1, LPF-I 2) (P < 0.001) lateral facet of the patella. No significant differences were evaluable for the relative patellar width (PW-I) (ns). A patellar shape type 3 (P = 0.001) as well as a higher position of the patella and TT-TG-distance (P < 0.001) were significantly more often present in the SG., Conclusion: There are several bony alterations associated with patellofemoral instability, but our data did not show a significantly smaller lateral patellar facet or relative patellar width that could facilitate a patellar dislocation. This helps surgeons, that are considering to surgically address the patella in cases of patellofemoral instability, to better understand its morphologic pattern., Level of Evidence: III.

Purpose: Medial open wedge high tibial osteotomy (owHTO) is a valuable surgical technique used to manage medial degeneration in varus knees. Iliac crest autograft is considered the gold standard gap-filler. It was hypothesised that iliac crest autograft promotes gap healing and improves functional outcome in owHTO., Methods: Between 2005 and 2009, patients scheduled to undergo owHTO stabilised by a medial locking compression plate were randomised to undergo owHTO either with iliac crest autograft (group A) or without bone void filler (group B). Pre- and postoperative leg axes were recorded. At 3 and 12 months postoperatively, the healing of the osteotomy gap was measured as a percentage on CT images, and functional scores were recorded., Results: There were 15 patients in group A, and 25 in group B. The groups were similar in age, sex ratio, knee varus deformity, body mass index, and smoking status. Group A and B had similar preoperative varus (6.9° vs. 7.6°) and postoperative valgus (2.2° vs. 3.0°). Compared with the control group, group A had a significantly greater degree of osseous gap healing after 3 months (40.1% vs. 10.8%, p = 0.045) and 12 months (91.5% vs. 59.1%, p ≤ 0.001). Multiple linear regression analysis found that bone grafting was an independent promoting factor for gap healing, while increased preoperative varus was an independent retardant factor at 3 months (p = 0.004 and p = 0.002, respectively) and 12 months (p ≤ 0.001 and p = 0.003, respectively). Younger age was a promoting factor for gap healing on CT at 3 months (p ≤ 0.001), but not at 12 months. No correlations were found between bone healing and functional outcome, body mass index, or smoking status., Conclusions: Iliac crest autograft significantly increases healing of the osteotomy gap after owHTO. Increased preoperative varus and older patient age are independent factors that delay early healing of the osteotomy. However, no functional advantage was found at 3 or 12 months postoperatively. Therefore, routine use of iliac crest autograft cannot be recommended., Level of Evidence: II.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Surgical principles for treatment of full-thickness cartilage defects of the knee include bone marrow stimulation techniques (i.e. arthroscopic microfracturing) and transplantation techniques (i.e. autologous chondrocyte implantation and osteochondral transplantation). On the basis of increasing scientific evidence, indications for these established therapeutical concepts have been specified and clear recommendations for practical use have been given. Within recent years, matrix-augmented bone marrow stimulation has been established as a new treatment concept for chondral lesions. To date, scientific evidence is limited and specific indications are still unclear. The present paper gives an overview of available products as well as preclinical and clinical scientific evidence. On the basis of the present evidence and an expert consensus from the "Working Group on Tissue Regeneration" of the German Orthopaedic and Trauma Society (DGOU), indications are specified and recommendations for the use of matrix-augmented bone marrow stimulation are given. In principle, it can be stated that the various products offered in this field differ considerably in terms of the number and quality of related studies (evidence level). Against the background of the current data situation, their application is currently seen in the border area between cell transplantation and bone marrow stimulation techniques, but also as an improvement on traditional bone marrow stimulation within the indication range of microfracturing. The recommendations of the Working Group have preliminary character and require re-evaluation after improvement of the study situation., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: In clinical practice, there is still no definite treatment algorithm for focal, partial thickness cartilage lesions (grade II - III). It is well-established that debridement (shaving/lavage) of large degenerative cartilage lesions is not recommended, but there is no such recommendation in the case of focal, partial thickness cartilage defects., Materials and Methods: The scientific rationale of cartilage shaving and joint lavage was investigated and a systematic analysis was performed of the literature on the clinical effect of cartilage debridement. Furthermore, a consensus statement on this issue was developed by the working group on Clinical Tissue Regeneration of the German Society of Orthopaedics and Trauma (DGOU)., Results: The therapeutic approach is different for asymptomatic lesions with biomechanical stable residual cartilage tissue and clinically symptomatic defects with unstable fragments. The benefit of a joint lavage or surface smoothening of focal partial thickness has not been proved. Even more importantly, the mechanical or thermal resection of cartilage tissue even induces a zone of necrosis in adjacent cartilage, and thus leads to additional injury. Therefore, large scale smoothening (shaving) of clinically asymptomatic, fibrillated or irregular cartilage defects should not be performed. However, if there are clinical symptoms, resection of unstable and delaminated cartilage fragments may be reasonable, as it can reduce harmful shear tension in residual tissue. This can help to brake the progression of the damage and avoid formation of free bodies., Conclusion: The decision criteria for debridement of partial thickness focal cartilage lesions are multifactorial and include the clinical symptoms, the size and the degree of the defect, the stability of remaining cartilage, localisation of the defect, and individual patient-specific parameters. Debridement is not recommended for asymptomatic lesions, but may be reasonable for symptomatic cases with unstable tissue., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Purpose: The purpose of the present study was to biomechanically compare three different posterior meniscal root repair techniques. Transtibial fixation of a posterior meniscus root tear (PMRT) combined with an anterior cruciate ligament (ACL) reconstruction via one tunnel only shows similar properties in terms of cyclic loading and load to failure compared with direct anchor fixation., Methods: Twenty-eight porcine knees were randomly assigned to 4 groups (n = 7 each): (1) native posterior meniscal root, (2) suture anchor repair, (3) refixation via a tibial ACL tunnel in combination with an interference screw fixation of the ACL graft, and (4) refixation via a tibial ACL tunnel in combination with an interference screw fixation of the ACL graft with an additional extracortical button fixation. The four groups underwent cyclic loading followed by a load-to-failure testing. Construct elongation during 1000 cycles, dynamic stiffness, attenuation, maximum force during load-to-failure testing, and failure mode were recorded., Results: All reconstructions showed a significant lower maximum load (p < 0.0001) compared with the native meniscal root. The elongation for the transtibial fixation via the ACL tunnel without an additional extracortical backup fixation was significantly higher compared with the suture anchor technique (p < 0.0001). The additional use of a backup fixation led to similar results compared with the anchor repair technique., Conclusion: The transtibial refixation of the meniscal root can be combined with an ACL reconstruction using the same tibial bone tunnel. However, an additional extracortical backup fixation is necessary. This might avoid a slippage of suture material and a failure of meniscus root fixation.

Purpose: To prospectively evaluate the prevalence and characteristics of meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures and to test for possible relationships between associated meniscal lesions and patient demographics or injury characteristics., Methods: A prospective multicenter study was conducted to arthroscopically assess the prevalence and characteristics of meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures between 04/2014 and 10/2015. Patient demographics and injury characteristics were assessed preoperatively. The presence of a meniscal injury was evaluated arthroscopically and characterized according to tear type and location (Cooper classification). Patients with and without meniscal injuries were compared with regard to sex, age, height, weight, BMI, type of injury, mechanism of injury, time to surgery, Tanner stage, sexual maturity (prepubescent vs. pubescent), and modified Meyers and McKeever classification., Results: A total of 54 consecutive patients (65 % males, mean age: 12.5 ± 3.2 years) were enrolled. Meniscal injury were found in 20 patients (37 %). The lateral meniscus was involved in 18 patients (90 % of all meniscus injuries) and the medial meniscus in 2 patients (10 % of all meniscus injuries). The most common tear pattern was a longitudinal tear of the posterior horn of the lateral meniscus (30 % of all meniscus injuries) and the second most common tear was a root detachment of the anterior horn of the lateral meniscus (20 % of all meniscus injuries). Higher age, advanced Tanner stage, and pubescence were significantly associated with an accompanying meniscal injury., Conclusion: Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures must be expected in almost 40 %, with a higher prevalence with increasing age and sexual maturity. With regard to the clinical relevance, the results of the present study argue in favor for magnetic resonance imaging prior to surgery in every patient with a suspected tibial eminence fracture and for an arthroscopic approach to adequately diagnose and treat meniscal injuries., Level of Evidence: II.

Background  Recreational sledging (tobogganing) is a very popular winter sport in Alpine regions. Ascending and sledging down on the same track, however, might be associated with a certain risk of injury. Therefore, the aim of this study was to gather data on the causes of accidents and potential risk factors during recreational sledging. Methods  Adults indulging in recreational sledging were interviewed between March 2013 and March 2015 at six public sledging tracks in the environs of the city of Innsbruck (Tyrol, Austria) on demographics, skill level, sledging frequency, risk-taking behavior, use of protective gear, type of sledge used, previous sledging-related injuries, injured body parts and causes of accidents. Interviews were conducted on all days of the week, mainly in the afternoon and in the evening. Results  A total of 3612 adults riding a sled (51.1 % males, 48.9 % females; mean age: 37.0 ± 14.4 years) participated in the present study. In total, 328 (9 %) participants reported a sledging-related injury. Injuries to lower extremities, arms, shoulder/back and head represented 41 %, 22 %, 11 %, and 10 %, respectively, of all sledging-related injuries. The most common causes of accidents were self-caused falls (35 %), collision with an object (23 %), and collision with another person (22 %). Sledging-related injuries in this study were associated with male sex, a higher sledging frequency, higher skill level, and risky behavior. In addition, those riding sledges who had suffered a previous injury were using more often a fast toboggan, wearing more often back protectors and wrist guards, had falls more often during sledging, and more often drank alcohol. Conclusion  Based on these findings, we recommend that individuals should adapt their behavior according to track, view and weather conditions, take into consideration the crowd on the track, and abstain from alcohol., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: This study evaluates sports ability, rotational laxity and potential growth changes in children after transphyseal ACL reconstruction with metaphyseal fixation technique, considering physis biology by placing drill holes vertically in the femoral anatomic origin in order to reduce volumetric injury to the physis., Methods: In this retrospective trial of 42 patients data were collected. Thirty-seven were reviewed measuring rotational laxity and anteroposterior tibial translation using the Laxitester (ORTEMA Sport Protection, Markgroeningen, Germany) and the KT1000. Clinical examination was evaluated with the IKDC 2000 knee examination form. Leg axis was determined with digital photography and leg length was assessed clinically. Sports ability was assessed with questionnaires including subjective IKDC, Tegner Activity Scale, Activity Rating Scale and a questionnaire on sports and level of sports., Results: Mean follow-up was 24.9months. Mean age at surgery was 13.2years in boys and 13.1years in girls. IKDC 2000 grading was A or B in 28 patients and C in nine patients. Significant increased anterior tibial translation was observed in neutral position and in external tibia rotation. No growth abnormalities were seen. Fifty-seven percent of the patients were able to participate in competitive sports at follow-up., Conclusion: Transphyseal ACL reconstruction with metaphyseal fixation in children with open growth plates can be done with low risk of growth changes. Return to competitive sports is possible although low rotational laxity still exists., Level of Evidence: IV., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Purpose: The purpose of this study was to develop a preventive exercise protocol based on structural and functional changes present in shoulder joints of young throwing athletes. As a proof of concept, these changes were previously evaluated in a cross-section of high-performance junior javelin throwers., Methods: Thirteen members of the German and Bavarian junior javelin squad (mean age 17.5 ± 0.8 years) completed a systematic clinical examination, shoulder range of motion (ROM) measurement, and were scored with standardized clinical tools. 3.0 tesla magnetic resonance imaging (MRI) was conducted on both shoulders. Bilateral three-dimensional analysis of the scapulothoracic motion during multiplanar humeral elevation and isokinetic strength testing of the shoulder internal and external rotators was accomplished. Based on the findings, a preventive exercise protocol was confirmed., Results: Dominant internal ROM was significantly decreased (dominant 48° ± 20° vs. non-dominant 57° ± 19°; P = 0.006) and dominant external ROM increased (dominant 117° ± 15° vs. non-dominant 107° ± 10°; P = 0.008). MRI revealed posterosuperior intraosseous cysts of the humeral head with a size larger than >3 mm in 69 % of the dominant shoulders and only in 15 % in the non-dominant shoulders. Motion analysis of the static scapular resting position was significantly different between dominant and non-dominant sides regarding anterior tilt (dominant > non-dominant, mean difference 4.2°, P = 0.010) and retraction (dominant > non-dominant, mean difference 2.4°, P = 0.038). Dominant scapular anterior tilt during flexion and abduction was significantly increased (-4.3°, P = 0.006; -3.4°, P = 0.046). Dominant retraction was significantly increased during abduction (-2.3°, P = 0.040). Isokinetic outcome parameters presented nonsignificant bilateral differences., Conclusions: Elite junior javelin throwers already present structural (humeral intraosseous cysts) and biomechanical changes (ROM deficits and asymmetric scapulothoracic motion patterns), even if they have no history of major shoulder pain or injury. A novel exercise protocol was developed in order to address the complex of alterations in a comprehensive way. Preventive diagnostics in combination with a systematic all-year preventive exercise intervention might be one option to detect and control risk factors of a symptomatic throwing shoulder at an early stage., Level of Evidence: IV.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: During recreational sledging (tobogganing), the head represents the most frequent injured body region with approximately one-third of all sledging injuries among children and adolescents. Whether children are wearing a helmet or not might be influenced on parental encouragement and role modeling of helmet use. Therefore, the aim of this study was to evaluate the impact of adult helmet use on child/adolescent helmet use in recreational sledging., Methods: More than 500 adults sitting together with another adult or child/adolescent on a two-seater sledge were interviewed during two winter seasons at the bottom of six sledging tracks on demographics, mean frequency of sledging per season, self-estimated skill level, risk-taking behavior, and the use of a helmet., Results: Total helmet use of all observed persons was 41.0 %. Helmet use among interviewed adults significantly increased with increasing age up to 45 years, frequency of sledging, and skill level, respectively. Helmet use of interviewed adults was 46.5 % if a child/adolescent was sitting on the same sledge and 29.8 % (odds ratios (OR): 2.1, 95 % confidence intervals (CI): 1.4-2.9, p < 0.001) when sledging together with another adult. Helmet use was 71.3 % among children/adolescents and 26.7 % among adults (OR: 6.8, 95 % CI: 4.6-10.1, p < 0.001) sitting on the same sledge as the interviewed person, respectively., Conclusion: Adults were wearing more often a helmet during recreational sledging when sitting together with a child/adolescent on the sledge. However, helmet use during sledging is clearly below 50 %. Thus, more intense educational campaigns on helmet use are urgently needed for tobogganists.

Purpose: The use of a low anteroinferior (5:30 o'clock) portal for arthroscopic shoulder stabilization allows an anatomical refixation of the capsulolabral complex. This anteroinferior portal, however, penetrates the inferior subscapularis (SSC), which is criticized. Therefore, the aim of the study was to evaluate the functional and structural properties of the SSC in patients with anteroinferior shoulder stabilization. The hypothesis was that it does not harm the SSC by demonstrating full muscular function and imaging-based normal structure at a long-term follow-up., Methods: Twenty patients were examined (14 males and six females; mean age 37.0 years) retrospectively after a mean follow-up of 9.6 years. At final follow-up, clinical examination and clinical scores (ASES, Constant-Murley, WOSI, and Rowe score) were documented. Additionally, SSC strength was evaluated with a custom-made electronic force measurement plate. All patients underwent bilateral magnetic resonance imaging to assess structural integrity and fatty infiltration (grading according to Fuchs et al.) of the SSC. Furthermore, vertical and transversal (superior and inferior) diameters of the muscle and the muscle area in a parasagittal plane were measured., Results: Clinical scores revealed good-to-excellent long-term results (ASES 92 points, Constant-Murley 82 points, WOSI 85 %, and Rowe 84 points). Force measurement in comparison with the contralateral side showed no significant (p > 0.05) differences for the 'belly-press' test (ipsilateral 102 N vs. contralateral 101 N) and the 'lift-off' test (73 vs. 69 N). There were also no significant differences between the mean diameters and the areas of the SSC muscle belly (vertical diameter ipsilateral 92 mm vs. contralateral 94 mm; superior transversal 28 vs. 29 mm; inferior transversal 34 vs. 34 mm; area 2336 vs. 2526 mm(2))., Conclusion: Arthroscopic labral repair with a low anteroinferior portal demonstrates no signs of structural and functional impairment of the SSC after 9.6 year follow-up. For clinical relevance, the lower part of the SSC can be penetrated for an optimal anchor placement in shoulder instabilities or Bankart fractures without concerns of a negative long-term effect on the SSC., Level of Evidence: Case series, Level IV.

Objective: To evaluate morphological and quantitative MR findings 9 years after autograft transfer of the posterior femoral condyle (Mega-OATS) and to correlate these findings with clinical outcomes. Quantitative MR measurements were also obtained of the contralateral knee and the utility as reference standard was investigated., Design: Both knees of 20 patients with Mega-OATS osteochondral repair at the medial femoral condyle (MFC) were studied using 3T MRI 9 years after the procedure. MR-sequences included morphological sequences and a 2D multislice multiecho (MSME) spin echo (SE) sequence for quantitative cartilage T2 mapping. Cartilage segmentation was performed at the cartilage repair site and six additional knee compartments. Semi-quantitative MR observation of cartilage repair tissue (MOCART) scores and clinical Lysholm scores were obtained. Paired t-tests and Spearman correlations were used for statistical analysis., Results: Global T2-values were significantly higher at ipsilateral knees compared to contralateral knees (42.1 ± 3.0 ms vs 40.4 ± 2.6 ms, P = 0.018). T2-values of the Mega-OATS site correlated significantly with MOCART scores (R = -0.64, P = 0.006). The correlations between MOCART and Lysholm scores and between absolute T2-values and Lysholm scores were not significant (P > 0.05). However, higher T2 side-to-side differences at the femoral condyles correlated significantly with more severe clinical symptoms (medial, R = -0.53, P = 0.030; lateral, R = -0.51, P = 0.038)., Conclusions: Despite long-term survival, 9 years after Mega-OATS procedures, T2-values of the grafts were increased compared to contralateral knees. Clinical scores correlated best with T2 side-to-side differences of the femoral condyles, indicating that intraindividual adjustment may be beneficial for outcome evaluation., (Copyright © 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Purpose: The current study was undertaken to better define the gross anatomical and dimensional characteristics of the proximal hamstring origin., Methods: Twelve paired whole-lower extremities from six embalmed cadavers were dissected. The gross anatomy of the proximal hamstrings was studied. With the tendons attached to the ischial tuberosity, the width and thickness of each tendon was measured 1 cm distally to their origin, and the distance from the most proximal border of the common origin of the semitendinosus (ST) and long head of the biceps (LB) to their distal junction was assessed. After removal of the hamstring group, the shape, orientation, and dimension of the tendon footprints were determined., Results: One cadaver demonstrated unique anatomy, which was considered as an anatomic variant and was therefore excluded from the study group. The ST and LB had a common origin on the posterolateral aspect of the ischial tuberosity (ST/LB), whereas the semimembranosus (SM) had a separated origin at the anterolateral aspect. The mean distance from the most proximal border of the ST/LB origin to the distal junction was 10.0 ± 1.3 cm. The shape of both footprints was longitudinal-oval, with the longitudinal axes of the SM and ST/LB footprints parallel aligned. Mean tendon width was 3.4 ± 0.5 cm for the common ST/LB complex and 4.2 ± 0.9 cm for the SM (p = 0.009). The corresponding values for tendon thickness were 1.0 ± 0.3 cm (ST/LB) and 0.8 ± 0.2 cm (SM), respectively (n.s.). Mean footprint length was 3.9 ± 0.4 cm for ST/LB and 4.5 ± 0.5 cm for SM (p = 0.002). The corresponding values for footprint height were 1.4 ± 0.5 cm (ST/LB) and 1.2 ± 0.3 cm (SM), respectively (n.s.)., Conclusion: The ST and LB had a common origin, whereas the SM originated separately. The site of origin of both tendons was the lateral aspect of the ischial tuberosity, with the SM footprint lying directly anterior to the footprint of the ST/LB complex. The footprint of the SM was significantly wider than the footprint of the ST/LB. The reported gross anatomic findings and dimensions may aid surgeons in anchor placement at the anatomical attachment site, thereby facilitating anatomic hamstring repair. In addition, the provided data may improve diagnosis and conservative treatment of proximal hamstring tendinopathy, since detailed knowledge about the normal anatomy is crucial for recognizing tendon abnormalities and for several conservative treatment modalities such as shockwave application or ultrasound-guided injections.

Background: Recreational sledging (tobogganing) is a very popular winter sport in the Alps. Therefore, injury prevention through the usage of protective gear seems important. Therefore, the aim of this study was to evaluate factors associated with the use of protective gear among adults during recreational sledging., Methods: Adult recreational sledgers were interviewed during the winter seasons 2012/13 and 2013/14 at six sledging tracks in Austria on demographics, skill level, sledging frequency, risk taking behaviour, sitting alone or with another person on the sledge, previous sledging-related injuries, and use of protective gear, respectively. Interviews were conducted on all days of the week., Results: A total of 1968 adult sledgers (49.4 % females) with a mean age of 37.1 ± 14.4 years participated in this study. A (ski) helmet, sun or snow goggles, a back protector, and wrist guards were used by 42.3 %, 71.0 %, 5.9 %, 2.6 % of sledgers, respectively. Helmet use was significantly higher with increasing age and increasing skill level as well as when sitting alone compared to sitting together with another person. Females, Austrians, persons sitting alone on the sledge, a higher frequency of sledging and a higher skill level were significantly associated with an increasing use of goggles. A back protector was significantly more often worn by younger people, more risky sledgers, and persons with a previous sledging-related injury. Wrist guards were significantly more often used by persons with a previous sledging-related injury., Conclusion: During recreational sledging, the factors age, sex, nationality, skill level, sitting alone compared to sitting together with another person on the sledge, sledging frequency, and injury experience were associated with the frequencies of usage of different types of protective gear. These factors should be considered when implementing preventive measures for recreational sledging., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To determine the impact of axial traction during high resolution 3.0T MR imaging of the ankle on morphological assessment of articular cartilage and quantitative cartilage imaging parameters., Materials and Methods: MR images of n=25 asymptomatic ankles were acquired with and without axial traction (6kg). Coronal and sagittal T1-weighted (w) turbo spin echo (TSE) sequences with a driven equilibrium pulse and sagittal fat-saturated intermediate-w (IMfs) TSE sequences were acquired for morphological evaluation on a four-point scale (1=best, 4=worst). For quantitative assessment of cartilage degradation segmentation was performed on 2D multislice-multiecho (MSME) SE T2, steady-state free-precession (SSFP; n=8) T2 and SSFP diffusion-weighted imaging (DWI; n=8) images. Wilcoxon-tests and paired t-tests were used for statistical analysis., Results: With axial traction, joint space width increased significantly and delineation of cartilage surfaces was rated superior (P<0.05). Cartilage surfaces were best visualized on coronal T1-w images (P<0.05). Differences for cartilage matrix evaluation were smaller. Subchondral bone evaluation, motion artifacts and image quality were not significantly different between the acquisition methods (P>0.05). T2 values were lower at the tibia than at the talus (P<0.001). Reproducibility was better for images with axial traction., Conclusion: Axial traction increased the joint space width, allowed for better visualization of cartilage surfaces and improved compartment discrimination and reproducibility of quantitative cartilage parameters., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Purpose: Hamstring injuries are among the most common muscle injuries seen in sports clinical practice. This narrative review covers essential knowledge of hamstring injuries, ranging from strains to total proximal three-tendon ruptures. The primary aim is to provide basic information for clinicians and sports medicine therapists dealing with hamstring problems., Methods: In this review, existing literature of hamstring injuries was taken together. Emphasis was given to subjects less well covered in previous reviews, such as preventive measures, as well as the most relevant information needed in the treatment of these injuries., Results: Occasionally, symptoms remain after hamstring injuries which can be successfully treated with surgery. Knowledge of the effectiveness of preventive measures and nonsurgical and surgical treatment is limited by small studies of low evidence level., Conclusions: Evidence-based treatment algorithms are not available. Larger studies of better quality with more concrete grading of hamstring tears are needed to improve knowledge in prevention and treatment of hamstring injuries., Level of Evidence: IV.

Purpose: The purpose of this study was to evaluate whether the expectable postoperative pain relief following valgus high tibial osteotomy (HTO) is reliably predictable with the temporary use of an unloading knee brace preoperatively., Methods: Fifty-seven patients with symptomatic varus malalignment were treated with a valgus producing unloading knee brace for 6-8 weeks. The pain intensity in the respective knee compartment was monitored using the visual analogue scale (VAS) before and following this treatment. A "positive" Brace-Test was defined as a pain relief medially without initiated symptoms laterally. In these cases, a valgus HTO was suggested as a promising surgical option. Patients who were subsequently operated were clinically re-evaluated 1 year postoperatively to compare the postoperative outcome with the result of the Brace-Test., Results: The mean VAS score decreased from 6.7 [standard deviation (SD) 1.6] to 2.5 points (SD 1.7) (p < 0.001) following the Brace-Test. Overall, 48 patients had a positive test. A valgus HTO was performed in 29 of them. The mean postoperative VAS score was 1.9 (SD 1.7) points with no difference to the result of the test (n.s.). Nineteen patients with a positive test initially decided for a conservative treatment. In three of nine patients with a negative test, a total knee replacement was performed., Conclusion: This study shows that the temporary use of an unloading valgus producing knee brace may well predict future outcome of HTO surgery in terms of expectable postoperative pain relief. The Brace-Test gives both the patient and the orthopaedic surgeon more detailed preoperative information, especially in critical or borderline indications. Thus, it is a useful tool to test the unloading effect before indicating an HTO., Level of Evidence: III.

Purpose: The objective of this retrospective study was to evaluate the functional results of distal biceps tendon repair using suture anchors via a single-incision approach., Methods: Forty-nine patients were re-examined at a mean follow-up of 44.2 ± 32.1 months (range, 12-119 months). Subjective and objective criteria included patient's satisfaction, active range of motion (ROM), maximum isometric strength in flexion (at 45° and 90°), and supination of both arms. Functional scoring included the Morrey elbow score (MES) and the QuickDASH. Furthermore, follow-up radiographs were performed., Results: Eighty-six percent of patients were highly satisfied or satisfied with their outcome. Compared to contralateral, the active ROM of elbow flexion, extension, and pronation was not affected; however, supination was decreased by 3° (P < 0.001). The isometric maximum strengths showed significant deficits in all tested scenarios (at 45°, P = 0.002; at 90°, P < 0.001; for supination, P < 0.001). The MES and the QuickDASH were 97.2 ± 4.9 and 7.9 ± 13.9, respectively. Heterotopic ossifications (HO) were found in 39% of patients; however, with respect to scores and strength, no significant differences were seen compared to patients without HO. Moreover, four anchor failures were detected., Conclusions: Single-incision suture anchor repair provides high patient's satisfaction and good results with respect to ROM and functional scoring. Nevertheless, based on presented data, the patient has to be informed of postoperative HO and especially for supination strength weakness after surgery. Distal biceps tendon repair should be reserved for experienced upper extremity surgeons to avoid procedure-related complications.

An avulsion of the tibial insertion of the meniscus or a radial tear close to the meniscal insertion is defined as a root tear. In clinical practice, the incidence of these lesions is often underestimated. However, several biomechanical studies have shown that the effect of a root tear is comparable to a total meniscectomy. Clinical studies documented progredient arthritic changes following root tears, thereby supporting basic science studies. The clinical diagnosis is limited by unspecific symptoms. In addition to the diagnostic arthroscopy, MRI is considered to be the gold standard of diagnosis of a meniscal root tear. Three different direct MRI signs for the diagnosis of a meniscus root tear have been described: Radial linear defect in the axial plane, vertical linear defect (truncation sign) in the coronal plane, and the so-called ghost meniscus sign in the sagittal plane. Meniscal extrusion is also considered to be an indirect sign of a root tear, but is less common in lateral root tears. During arthroscopy, the function of the meniscus root must be assessed by probing. However, visualization of the meniscal insertions is challenging. Refixation of the meniscal root can be performed using a transtibial pull-out suture, suture anchors, or side-to-side repair. Several short-term studies reported good clinical results after medial or lateral root repair. Nevertheless, MRI and second-look arthroscopy revealed high rates of incomplete or absent healing, especially for medial root tears. To date, most studies are case series with short-term follow-up and level IV evidence. Outerbridge grade 3 or 4 chondral lesions and varus malalignment of >5° were found to predict an inferior clinical outcome after medial meniscus root repair. Further research is needed to evaluate long-term results and to define evident criteria for meniscal root repair.

Alpine skiing is the most popular winter sport discipline in Germany and is performed by more than 4 million recreational sportsmen and ski racing athletes. Compared to other sports, however, the injury rate in alpine skiing is quite high. Especially the knee joint is the most commonly injured area of the musculoskeletal system. Knee injuries are classified as severe in a high percentage of cases. In this review article, epidemiologic data and typical injury patterns in recreational alpine skiing and in competitive alpine ski racing are compared. In addition, the potentials of preventive methods in alpine skiing are presented and evaluated with a special focus on orthotic devices and protection wear as injury prevention equipment.

Background: The purpose of this study was to evaluate clinical and magnetic resonance imaging (MRI) findings in the shoulders of high performance competitive junior javelin athletes and volleyball players. The hypothesis was that structural lesions already exist in young and asymptomatic overhead athletes., Methods: Thirty-one healthy high performance junior elite athletes were included. Group 1 consisted of 15 male javelin throwers (mean age, 17.7 ± 0.8 years) and group 2 of 16 male volleyball players (16.9 ± 1.0 years). Questionnaire-based interviews, comprehensive clinical examination, and shoulder scoring systems (visual analog scale [VAS] and Constant-Murley Score) were completed. Bilateral shoulder imaging was performed using a 3.0 Tesla MRI., Results: The Constant-Murley Score of group 1 was 95.5 ± 3.6 and 94.7 ± 4.6 points for group 2. Group 1 demonstrated a mean VAS of 0.9 ± 1.6 and group 2 a mean of 0.6 ± 0.8 points. Postero-superior intraosseous cysts of the humeral head were detected in 73.3% of all javelin throwers in the dominant shoulder, but only in 13.3% in the nondominant shoulder (P = .008). In the volleyball group, such cyst formation was rarely seen in 12.5% in the dominant versus 6.3% in the nondominant shoulder (P = .66)., Conclusion: A high percentage of junior elite athletes already demonstrate osseus signs of overloading especially in the group of javelin athletes, although none had a history of prior shoulder pathology. Therefore, junior overhead athletes might be at risk for the early development of structural lesions at the insertion of the posterior rotator cuff similar to lesions already known for adult athletes, even though they do not present clinical signs of overuse at that age., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Purpose: A steep tibial slope may contribute to anterior cruciate ligament (ACL)-injuries, a higher degree of instability in the case of ACL insufficiency, and recurrent instability after ACL reconstruction. A better understanding of the significance of the tibial slope could improve the development of ACL injury screening and prevention programmes, might serve as a basis for individually adapted rehabilitation programmes after ACL reconstruction and could clarify the role of slope-decreasing osteotomies in the treatment of ACL insufficiency. This article summarizes and discusses the current published literature on these topics., Methods: A comprehensive review of the MEDLINE database was carried out to identify relevant articles using multiple different keywords (e.g. 'tibial slope', 'anterior cruciate ligament', 'osteotomy', and 'knee instability'). The reference lists of the reviewed articles were searched for additional relevant articles., Results: In cadaveric studies, an artificially increased tibial slope produced an anterior shift of the tibia relative to the femur. While mathematical models additionally demonstrated increased strain in the ACL, cadaveric studies have not confirmed these findings. There is some evidence that a steep tibial slope represents a risk factor for non-contact ACL injuries. MRI-based studies indicate that a steep slope of the lateral tibial plateau might specifically be responsible for this injury mechanism. The influence of the tibial slope on outcomes after ACL reconstruction and the role of slope-decreasing osteotomies in the treatment of ACL insufficiency remain unclear., Conclusion: The role of the tibial slope in sustaining and treating ACL injuries is not well understood. Characterizing the tibial plateau surface with a single slope measurement represents an insufficient approximation of its three-dimensionality, and the biomechanical impact of the tibial slope likely is more complex than previously appreciated., Level of Evidence: IV.

Background: Studies on the biomechanical properties of meniscus repairs are usually performed at room instead of body temperature. However, various all-inside meniscal repair devices include bioabsorbable materials, which are mechanically sensitive to higher environmental temperatures. Therefore, we hypothesize that current test standards may systematically lead to a false overestimation of their performance., Methods: In 84 cadaveric bovine lateral menisci, an artificial vertical lesion was repaired with different all-inside meniscal repair devices (FasT-Fix, FasT-Fix AB, RapidLoc, Meniscus Arrow, Meniscus Screw) compared to a vertical inside-out Ethibond Excel 2.0 suture loop. Maximum load-to-failure, stiffness, and failure mode were tested in a uniaxial distraction loading at 20°C and 37°C., Findings: Most of the tested implants were not susceptible to the higher environmental test temperature with respect to maximum load-to-failure, stiffness, and failure mode. Only the RapidLoc showed a significantly decreased stiffness (-28.1%) and a statistical trend to lower maximum load-to-failure (-20.6%) at 37°C compared to 20°C., Interpretation: 20°C environmental temperature seems to be an acceptable test condition for the most meniscal repair devices. However, if the bioabsorbable part of the implant is the weakest link, body temperature may be considered for testing to prevent false overestimation of the biomechanical properties. For future biomechanical in vitro testing of meniscal repair devices, this study may provide novel insight into biomechanical test protocols for considering the environmental test temperature as an influencing factor of the biomechanical properties of especially bioabsorbable meniscal repair devices., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Eccentric training (ET) has been shown to be an effective conservative treatment option for chronic patellar and Achilles tendinopathies. As part of the four-muscle-tendon-complex of the rotator cuff, the supraspinatus is involved most commonly in shoulder disorders. Histopathologic alterations of the supraspinatus tendon are comparable to findings in lower extremity tendinopathies. Hence, the question arises whether the concept of eccentric training can be successfully transferred to the upper extremity. Yet, no randomised controlled trials have been published to support this theory. This problem emerges from the fact that the supraspinatus is part of a complex functional unit. Consequently, surrounding soft tissues are frequently concomitantly affected. The inherent etiology and genesis of pathologic alterations in the supraspinatus tendon and its influence on shoulder disorders is not clear to date. However, the apparent success of ET in managing tendinopathies of the lower extremity urges further scientific work for developing evidence-based guidelines for the conservative treatment of tendinopathies in the shoulder region. Taking into account this lack of data as well as the anatomical and functional constraints, the aim of this work is to review the current state of the literature., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: A novel double-row configuration was compared with a traditional double-row configuration for rotator cuff repair., Methods: In 10 matched-pair sheep shoulders in vitro repair was performed with either a double-row technique with corkscrew suture anchors for the medial row and insertion anchors for the lateral row (group A) or a double-row technique with a new tape-like suture material with insertion anchors for both the medial and lateral rows (group B). Each specimen underwent cyclic loading from 10 to 150 N for 100 cycles, followed by unidirectional failure testing. Gap formation and strain within the repair area for the first and last cycles were analyzed with a video digitizing system, and stiffness and failure load were determined from the load-elongation curve., Results: The results were similar for the 2 repair types. There was no significant difference between the ultimate failure loads of the 2 techniques (421 +/- 150 N in group A and 408 +/- 66 N in group B, P = .31) or the stiffness of the 2 techniques (84 +/- 26 N/mm in group A and 99 +/- 20 N/mm in group B, P = .07). In addition, gap formation was not different between the repair types. Strain over the repair area was also not different between the repair types., Conclusions: Both tested rotator cuff repair techniques had high failure loads, limited gap formation, and acceptable strain patterns. No significant difference was found between the novel and conventional double-row repair types., Clinical Relevance: Two double-row techniques-one with corkscrew suture anchors for the medial row and insertion anchors for the lateral row and one with insertion anchors for both the medial and lateral rows-provided excellent biomechanical profiles at time 0 for double-row repairs in a sheep model. Although the sheep model may not directly correspond to in vivo conditions, all-insertion anchor double-row constructs are worthy of further investigation.

The optimal technique of posterior cruciate ligament (PCL) reconstruction is still controversial. Besides different parameters as surgical technique and graft choice, the exact anatomic placement of the graft is essential for successful reconstruction of the PCL. For intraoperative control and postoperative radiological evaluation of the anatomical placement of the anterolatelateral (ALB) and posteromedial bundle (PMB) of the PCL, the radiological localization of both functional bundles of the PCL has yet to be determined. Therefore, in this descriptive laboratory study, the insertion sites of the ALB and PMB of the PCL on the femur and the common tibial insertion site were macroscopically identified and marked with copper wires in 16 human cadaver specimens. Radiological evaluation of the femoral insertion sites of the ALB and PMB in AP full extension and true lateral radiography was performed using an angle segment transformation based on the tangent of the femoral condyles and a modified reticule system of the quadrant method, respectively. On the tibial site, the footprint of the PCL was defined as ratios of the geometric insertion site with respect to the mediolateral and sagittal diameter of the tibia in AP and true lateral radiography. Femorally, the geometric insertion points of the ALB and PMB were located on the reticule at x = 62 +/- 3%/y = 16 +/- 6% and x = 51 +/- 5%/y = 35 +/- 7%, respectively; the angle segments for the PMB were between 40 +/- 5 degrees and 56 +/- 6 degrees and for the ALB were between 56 +/- 6 degrees and 76 +/- 7 degrees. Tibially, the common insertion point of the PCL was located at 51 +/- 2% of the mediolateral diameter of the tibial plateau with respect to the lateral border and 13 +/- 2% inferiorly to the medial tibial plateau with respect to the sagittal diameter of the tibial plateau. In conclusion, the knowledge of the anatomical insertion sites of the PCL in standardized radiography may help the orthopaedic surgeon for correct intraoperative placement and postoperative evaluation of the tunnel placement. In addition, the data might be a useful tool for fluoroscopic-based navigation in PCL reconstruction.

Objective: Restoration or preservation of the loading tolerance of the knee joint. Delay of the development of degenerative arthrosis., Indications: Extensive osteochondral defects (traumatic, posttraumatic, osteochondrosis dissecans, focal osteochondronecrosis) within the weight-bearing zone of the femoral condyle. Comorbidities such as malalignment and ligament instabilities should be addressed prior to or, ideally, simultaneously with the Mega-OATS intervention., Contraindications: Delocalized uni- and multicompartmental osteochondral lesions of the knee. Tricompartmental knee arthrosis. Acute and chronic arthritis or infection of the knee. Chondrocalcinosis. Not simultaneously corrected or noncorrectable malalignment or ligamentous instabilities. Patient's age > 55 years. Postoperative continuation of activities with high loading stresses at high knee flexion angles, e.g. pavior, downhill ski racer., Surgical Technique: Anteromedial or anterolateral arthrotomy. Exposure and measurement of the affected osteochondral area. Reaming of the defect until attainment of a vital bed of the defect. Measurement of the depths of the prepared defect. Removal of the medial posterior femoral condyle. Preparation of the cylinder of the transplant harvested from the removed posterior femoral condyle using a specially designed Mega-OATS workstation (diameter between 20 and 35 mm). Placement of the Mega-OATS cylinder in press-fit technique., Postoperative Management: Initial continuous passive motion therapy, active range of motion 90 degrees -0 degrees -0 degrees , and unloading for 6 weeks postoperatively using crutches, followed by progressive weight bearing with 20 kg per week until full weight bearing. Free active range of motion as tolerated from 7th week. Four-point hard-frame knee orthosis for 6 weeks. Concomitant intensive muscle and proprioceptive training from 3rd to 6th month. Specific sports rehabilitation program starting 7th month., Results: The initial 17 and 16 patients following Mega-OATS procedure due to a large osteochondral defect (average size 6 cm2, range 4-9 cm2) of the femoral condyle were clinically examined including an image-guided evaluation protocol at an average follow-up of 12 and 55 months, respectively. In the Lysholm Score, there was a significant increase from 62 +/- 4 points (mean +/- SEM [standard error of the mean]) preoperatively to 85 +/- 7 points at 12 months and 81 +/- 4 points at 55 months postoperatively. In nine patients with varus malalignment, a simultaneous high tibial osteotomy was performed. However, a significant difference in the Lysholm Score between the subgroup with and without simultaneous high tibial osteotomy could not be found. In more than 90% of the patients, a high subjective satisfaction rate was noted. Randomized magnetic resonance images revealed a good viability of the Mega-OATS graft as well as an intact posterior horn of the ipsilateral meniscus.

Allografts have an essential significance in the surgical reconstruction of ligamentous injuries around the knee joint. While in primary anterior cruciate ligament reconstruction allografts are less important than autografts, at least in the European countries, the usage of allografts in anterior cruciate ligament revision surgery is increasing. In addition, allografts represent a good alternative for the reconstruction of the posterior cruciate ligament and the posterolateral structures. Especially in multiligament reconstructions of the knee joint, the usage of allografts may prevent iatrogenic damage of the already traumatized periarticular soft tissue. The present article focuses on the application and clinical results of allografts for ligament reconstruction around the knee joint. Furthermore, the immunological and biological principles of tendon allografts, their availability, processing, and security are discussed.

Patients continue to suffer residual pain and instability following anterior cruciate ligament reconstruction. Although overall outcomes of anterior cruciate ligament reconstruction are favorable, improved outcomes can be achieved. Recent biomechanical studies have questioned the ability of conventional single-bundle anterior cruciate ligament constructs to adequately restore normal knee kinematics. Consequently, the use of double-bundle anterior cruciate ligament constructs has been recommended to restore knee stability more effectively. Recent biomechanical data indicate that double-bundle anterior cruciate ligament reconstruction may provide better anteroposterior and rotational knee stability than do conventional single-bundle techniques. Studies are needed to evaluate the clinical impact of double-bundle reconstruction techniques on long-term functional outcomes.