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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patellofemoral instability is one of the most common pathologies of the knee joint. The planning and implementation of patella-stabilizing operations are very variable. With regard to the operative measures, the preoperative planning is of decisive importance, especially with regard to the complexity of underlying pathologies.The aim of this study was to depict the current healthcare reality in relation to planning and implementation of patella stabilizing operations in Germany. Furthermore, it was to be ascertained whether automated analysis options would facilitate the planning and implementation of surgical procedures (in primary and revision cases).An online survey with 16 questions was collected by email among all active members of the German Society of Orthopedic and Trauma Surgery. 7974 members were surveyed; 393 responses could then be analyzed.MPFL-reconstruction (89.8%) is the most frequently performed procedure, followed by tibial tubercle transfers (64.9%), osteotomies (51.2%), and trochleoplasty (19.9%). The choice of surgical approach is mainly based on a combination of clinical and radiological findings (90.3%). MRI imaging (81.2%), standard X‑ray images (77.4%), and full leg images (76.6%) are mainly used for operative treatment decisions. 59.3% of the respondents would appreciate better preoperative planning and 59.0% would implement more radiologically detectable parameters in their individual preoperative planning if these were automatically available.The findings of this survey among members of the DGOU identify the MPFL-reconstruction as the central operative approach in the treatment of patellofemoral instabilities, whereas MRI imaging is the diagnostic tool of choice. Future establishment of automated software-based analysis methods could allow a large number of surgeons to expand the radiological parameters taken into account when planning patella-stabilizing operations.HINTERGRUND: Die patellofemorale Instabilität zählt zu den häufigsten Pathologien des Kniegelenks. Die Planung und Durchführung patellastabilisierender Operationen ist sehr variabel. Bezüglich der operativen Maßnahmen kommt der präoperativen Planung, gerade im Hinblick auf die häufig hohe Komplexität der zugrundeliegenden Pathologien, eine entscheidende Bedeutung zu.Ziel dieser Studie war es, die aktuelle Versorgungsrealität in Bezug auf Planung und Durchführung patellastabilisierender Operationen unter Mitgliedern der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) abzubilden. Des Weiteren sollte erhoben werden, ob ggf. automatisierte Analysen der zugrundeliegenden Anatomie die Planung und Durchführung patellastabilisierender Operationen (im Primär- und Revisionsfall) beeinflussen würden.Unter allen aktiven Mitgliedern der DGOU wurde per Mail eine anonymisierte Online-Umfrage mit 16 Fragen erhoben. 7974 Mitglieder wurden angeschrieben, 393 Rückmeldungen konnten anschließend analysiert werden.Die MPFL-Plastik (89,8 %) ist die am häufigsten durchgeführte Operation zur Patellastabilisierung. Dahinter folgen Tuberositasversatzoperationen (64,9 %), Korrekturosteotomien (51,2 %) und Trochleaplastiken (19,9 %). Die Wahl bezüglich des operativen Vorgehens fällt überwiegend auf Grundlage einer Kombination aus klinischen und radiologischen Befunden (90,3 %). Für die Entscheidung zur Operation werden hauptsächlich MRT-Bildgebung (81,2 %), Standard-Röntgenbilder (77,4 %) und Beinganzaufnahmen (76,6 %) herangezogen. Insgesamt würden 59,3 % der Befragten eine automatisierte Analyse für eine vereinfachte präoperative Planung und die Detektion von entscheidenden radiologischen Parametern (59,0 %) in Anspruch nehmen, sofern diese zur Verfügung stünden.Die Erhebungen dieser Umfrage unter Mitgliedern der DGOU weisen die MPFL-Plastik als zentralen Ansatzpunkt zur operativen Behandlung patellofemoraler Instabilitäten aus, diagnostisch ist die MRT-Bildgebung essenziell. Durch eine zukünftige Etablierung automatisierter Software-gestützter Analysemethoden könnte bei einer Vielzahl von Operateuren eine Erweiterung der radiologisch berücksichtigten Parameter in der Planung patellastabilisierender Operationen erreicht werden.

BackgroundAlthough of high relevance for clinical decision making, there exists no consensus throughout the literature of the terms “acute” and “traumatic” used in the classification of rotator cuff tears. With differing definitions, the comparability of outcome studies may be limited. The aim was to provide a detailed systematic review of the definitions used in the literature and present a suggestion for a standardization in nomenclature based on the findings.MethodsFour different internet databases were searched in February 2020 using the terms (“acute” OR “traumatic” OR “trauma” OR “athlete” OR “young”) AND (“rotator cuff tears” OR “rotator cuff tear” OR “rotator cuff” OR “rotator cuff rupture” OR “supraspinatus” OR “infraspinatus” OR “subscapularis” OR “teres minor”). Prospective, retrospective, cohort and case–control studies as well as case series were included. Systematic reviews, cadaveric or laboratory studies and studies on non-traumatic or non-acute rotator cuff tears were excluded.ResultsThe literature search conducted 10,349 articles of which 10,151 were excluded based on the title, 119 based on the abstract and 33 based on the manuscript. A total of 46 studies were finally included for review and subsequently analyzed. Overall, there exists no consensus neither on the term “acute” nor on “traumatic” in the context of rotator cuff tears in the literature. The time span for acute injuries ranged between 2 weeks and 6 months. For traumatic injuries, only 20% of the selected studies described a specific and adequate injury mechanism in combination with adequate imaging.ConclusionThe term “acute” should be reserved for RCT showing muscle edema, wavelike appearance of the central part of the torn tendon and joint effusion, which typically requires adequate imaging within 2 weeks from trauma. Repair of acute tears should occur within 8 weeks from trauma to benefit from possibly superior biological healing capacities. The term “traumatic” should be used for a sudden onset of symptoms in a previously asymptomatic patient, triggered by an adequate trauma, e.g., a fall on the retroverted arm with an axial cranioventral force or a traumatic shoulder dislocation.

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

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

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

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

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

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

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

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

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

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

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

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

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

Zum Stellenwert der Bandrekonstruktion bei bestehender Arthrose werden drei Themen vorgestellt: Arthroseentstehung nach VKB(vorderes Kreuzband)-Ruptur oder -Ersatz, VKB-Ersatz bei bestehender Gonarthrose, VKB-Ersatz zusammen mit medialer Schlittenprothese. Risikofaktoren fur eine Arthroseentstehung und -progredienz bei VKB-Ruptur sind die Begleitverletzungen v. a. am Meniskus und der Knorpelschaden v. a. am Kniescheibengelenk. Die Behandlung einer symptomatischen VKB-Insuffizienz bei bestehender Gonarthrose am Beispiel des alteren Patienten hangt direkt von den schon vorbestehenden Verschleiszeichen ab. Die mediale Schlittenprothese und der VKB-Ersatz wiederum sind gut miteinander vereinbar und fuhren zu sehr guten Langzeitergebnissen, auch beim jungeren Patienten.

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

Unicompartmental knee arthroplasty, especially for both femorotibial compartments of the knee, is an established partly joint-saving treatment option for osteoarthritis of the knee if the disease is limited to one compartment. Even smaller implants or resurfacing of the patellofemoral joint have been shown-in smaller patient collectives-to have the potential to yield good clinical results.Insbesondere der unikompartimentelle Ersatz der beiden femorotibialen Kompartimente des Kniegelenkes stellt eine etablierte teilweise gelenkerhaltende Behandlung der lokal begrenzten Gonarthrose dar. Auch kleinere, fokale Implantate und der Oberflächenersatz des Patellofemoralgelenkes zeigen in kleineren Studienkollektiven gute Ergebnisse. Gute Indikationsstellungen und korrekte technische Ausführung sind jedoch Grundvoraussetzungen für reproduzierbar zufriedenstellende Ergebnisse.

Commonly used cartilage repair procedures have been established for focal cartilage lesions; however, degenerative lesions with accompanying changes of other intraarticular structures are much more common in clinical practice. This stage, in which classic radiological signs of osteoarthritis are absent, is called early osteoarthritis and is characterized by impaired joint homeostasis with biomechanical and biochemical changes that can have a negative effect on regenerative cartilage therapy procedures.Cartilage repair procedures are indicated for symptomatic focal early osteoarthritis, defined as cartilage degeneration ICRS grades I or II around a focal cartilage defect ICRS grades III or IV. In more advanced osteoarthritis with significant narrowing of the joint space, cartilage repair procedures are generally contraindicated.The most studied cartilage repair procedure for early osteoarthritis is autologous chondrocyte implantation, which has shown acceptable results in case series, although higher failure rates are to be expected compared to focal, traumatic cartilage lesions. The use of bone marrow-stimulating techniques seems to be limited in early osteoarthritis and should only be used in cases of lesion 2 cmHINTERGRUND: Im klinischen Alltag angewandte chirurgische Knorpeltherapieverfahren sind für fokale Knorpelschäden etabliert, allerdings sind in der Versorgungsrealität degenerative Knorpelschäden mit Affektion weiterer Kniebinnenstrukturen wesentlich häufiger. Dieses Stadium, in welchem klassische radiologische Arthrosezeichen fehlen, wird als Früharthrose bezeichnet und ist gekennzeichnet durch eine gestörte Gelenkhomöostase mit biomechanischen und biochemischen Veränderungen, welche sich negativ auf regenerative Knorpeltherapieverfahren auswirken können.Die Indikation zur chirurgischen Knorpeltherapie besteht bei der symptomatischen fokalen Früharthrose, welche nach Madry et al. definiert ist als Knorpeldegeneration ICRS(International Cartilage Repair Society)-Grad I oder II welche um einen fokalen Knorpelschaden ICRS-Grad III oder IV lokalisiert ist. Bei fortgeschrittener Arthrose mit deutlicher Gelenkspaltverschmälerung sind sämtliche chirurgischen Knorpeltherapieverfahren im Allgemeinen nur in Ausnahmefällen indiziert.Das am besten untersuchte Verfahren bei der Früharthrose ist die autologe Chondrozytentransplantation, welche in Fallserien akzeptable Ergebnisse erzielte, allerdings muss mit höheren Versagensraten als bei fokalen, traumatischen Knorpelschäden gerechnet werden. Der Nutzen von knochenmarkstimulierenden Techniken scheint bei der Früharthose limitiert zu sein und sollte lediglich bei kleinem Schaden 2 cm

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

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