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The aim of this study was to generate more information on the etiology and pathogenesis of medial (MM) and lateral (LM) meniscus root tears. Our hypothesis was that root tears of the MM predominantly result from degenerative damage, whereas root injuries of the LM are mainly of traumatic origin.Consecutively, 53 patients with a root tear of the medial meniscus (MMRT) and 51 patients with a root tear of the lateral meniscus (LMRT) were included in this study. The diagnosis was confirmed radiologically by MRI as well as arthroscopically. In addition to patient-specific data such as age, BMI and trauma history, the leg axis was determined and accompanying injuries (ligamentous and chondrogenic) were documented.The mean age of the MMRT group was 57.2 (± 11.2) years, and that of the LMRT group 33.9 (± 11.4) years. The BMI was significantly higher in the MMRT group compared to the LMRT (30.5 vs. 25.1). 82.4% of patients in the LMRT group demonstrated an accompanying anterior cruciate ligament (ACL) rupture, whereas only 5.7% of the MMRT were associated with an ACL injury. A trauma was described in only 13.2% of patients of the MMRT group in contrast to 88.2% of the LMRT group. An extrusion 3 mm of the MM in the coronal plane of MRI images could be detected in 86.8% of patients, whereas in the LMRT group, it was 15.7%. The mechanical varus angle was 5.6° in the MMRT group and 2.4° in the LMRT group. The rate and degree of concomitant cartilage damage in the affected compartment was significantly higher in the group with medial root injuries than in the group with lateral root tears.The root injuries of the MM and LM show significant differences in terms of patient age, etiology and accompanying injuries. Root injuries to the medial meniscus are mostly of non-traumatic origin and more likely to occur in the context of medial osteoarthritis and varus deformity of the knee. Lateral root tears tend to be predominantly traumatic and are frequently associated with ACL ruptures. However, in the MMRT group, a small subgroup with a traumatic etiology and in the LMRT group a small subgroup of patients with non-traumatic etiology could be identified.III.

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.

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.

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.

Background: In current magnetic resonance imaging (MRI) of the knee, injuries to the anterolateral ligament complex (ALC) and the Kaplan fibers (KFs) are not routinely assessed. As ruptures of the KFs contribute to anterolateral rotatory instability in the anterior cruciate ligament–deficient knee, detecting these injuries on MRI may help surgeons to individualize treatment. Purpose: To visualize the KFs on 3-T MRI and to conduct a layer-by-layer dissection of the ALC. Study Design: Descriptive laboratory study. Methods: Ten fresh-frozen human cadaveric knees (mean ± SD age, 72 ± 8.5 years) without history of ligament injury were used in this study. Before layer-by-layer dissection of the ALC, MRI was performed to define the radiologic anatomy of the KFs. A coronal T1-weighted 3-dimensional turbo spin echo sequence and a transverse T2-weighted turbo spin echo sequence were obtained. Three-dimensional data sets were used for multiplanar reconstructions. Results: KFs were identified in 100% of cases on MRI and in anatomic dissection. The mean length of the proximal and distal KFs was 17.9 ± 3.6 mm and 12.4 ± 6.5 mm, respectively. On MRI, the distance from the lateral femoral epicondyle to the proximal KFs was 35.9 ± 6.9 mm and to the distal KFs, 16.6 ± 4.1 mm; in anatomic dissection, the distances were 41.4 ± 8.1 mm for proximal KFs and 28.2 ± 8.1 mm for distal KFs. The distance from the lateral joint line to the proximal KFs was 63.5 ± 7.6 mm and to the distal KFs, 45.3 ± 3.7 mm. Interobserver reliability for image analysis was excellent for all measurements. Conclusion: KFs can be consistently identified on MRI with use of 3-dimensional sequences. Subsequent anatomic dissection confirmed their close topography to the superior lateral genicular artery. For clinical implications, the integrity of the KFs should be routinely reviewed on MRI scans Clinical Relevance: As ruptures of the KFs contribute to anterolateral rotatory instability, accurate visualization of the KFs on MRI may facilitate surgical decision making for additional anterolateral procedures in the anterior cruciate ligament–deficient knee.

Eine Meniskusresektion sowie eine varische Beinachse sind unabhangige Risikofaktoren fur eine Uberlastung des medialen Kniekompartiments und folglich fur die Entwicklung einer medialen Gonarthrose. Das Ziel dieser biomechanischen Studie war es, den Effekt der Beinachse auf Veranderungen des Kontaktdrucks und der Kontaktflache nach sequenzieller Innenmeniskusresektion zu untersuchen. Acht humane Kniekadaver wurden mit einer axialen Kompressionskraft von 750 N in 0° Flexion belastet. Die mechanische Beinachse kreuzte das Tibiaplateau auf jeweils 30 %, 40 % 50 %, 60 % und 70 %. Mit jeweils separaten drucksensitiven Sensoren (K-Scan 4000, Tekscan) wurde der mittlere tibiofemorale Kontaktdruck (MCP), der Maximaldruck (PCP) sowie die Kontaktflache (CA) im medialen und lateralen Kompartiment nach 4 Meniskusresektionsgraden (intakt, 50 % Resektion, 75 % Resektion, totale Meniskektomie) gemessen. Im Vergleich zum intakten Meniskus war der mediale MCP nach Meniskusresektion in jeder getesteten Beinachse signifikant erhoht (p

Verletzungen der ischiokruralen Muskulatur zahlen zu den haufigsten Muskelverletzungen des Menschen, wobei der Abriss der proximalen Hamstring-Sehnen eine besonders schwerwiegende Form darstellt. Die operative Therapie dieser Verletzungen ist dem konservativen Management hinsichtlich Patientenzufriedenheit, Wiederherstellung der Muskelkraft und Funktion sowie „return to sports“ uberlegen und deshalb Methode der Wahl. Darstellung und Vergleich der operativen Ergebnisse nach Versorgungen mit Titan‑, Polyetheretherketon(PEEK)- oder „All-suture“-Anker. Es wurde eine systematische Literatursuche in der Medizindatenbank PubMed durchgefuhrt, und die Ergebnisse wurden zusammengefasst. Alle Systeme zeigen vergleichbare biomechanische Elongations- sowie Maximallastwerte. Operationen mit diesen Ankern resultieren in guten klinischen Ergebnissen und weisen niedrige Komplikations- und eine hohe Return-to-sports-Raten auf. Die Patientenzufriedenheit nach Hamstring-Sehnen-Repair betragt uber 90 % und die Return-to-sports-Raten 80–100 %. Die Muskelkraft wird im Vergleich zur Gegenseite zu etwa 80–90 % wiederhergestellt. Alle Ankertypen sind sicher anwendbar, und ein expliziter Vorteil fur ein Ankersystem konnte bis dato nicht nachgewiesen werden.

Displaced tibial posterior cruciate ligament (PCL) avulsion fractures require surgical fixation in order to provide an adequate bone healing and to avoid a loss of posterior stability. The purpose of this study was to compare the biomechanical properties of a recently established modified suture bridge technique to a well-established transtibial pullout technique. It was hypothesized that the suture bridge technique shows lower elongation and higher load to failure force compared to a transtibial pullout fixation. Twelve fresh-frozen human cadaveric knees were biomechanically tested using an uniaxial hydrodynamic material testing system. A standardized bony avulsion fracture of the tibial PCL insertion was generated. Two different techniques were used for fixation: (A) suture bridge configuration and (B) transtibial pullout fixation. In 90° of flexion elongation, initial stiffness and failure load were determined. The suture-bridge technique resulted in a significant lower elongation (4.5 ± 2.1 mm) than transtibial pullout technique (12.4 ± 3.0 mm, p

Anatomische Refixation knocherner tibialer Avulsionsverletzungen des hinteren Kreuzbandes (HKB) mit SutureBridge™-Technik (Arthrex, Naples, FL, USA) zur Wiederherstellung der posterioren Kniegelenkstabilitat. Akute tibiale knocherne Avulsion des HKB, ggf. mehrfragmentare Avulsionsfrakturen. Chronische Fraktursituation, chronische posteriore Instabilitat, fortgeschrittene Gonarthrose, hochgradige Weichteilverletzung, Infektion. Bauchlage; minimal-invasiver dorsomedialer Zugang; Frakturdarstellung und Reposition; Einbringen eines proximalen Fadenankers (interfragmentar); Anschlingen des HKB und Verknoten der Tapes zur zentralen Readaptation des Fragments; Abspannen der Tapeenden uber zwei distale Fadenanker zur dorsalen Readaptation. Kniestreckschiene mit posteriorem tibialem Support fur 6 Wochen, 20-kg-Teilbelastung und limitierte Flexion bis 90°, Physiotherapie in Bauchlage ab 1. postoperativem Tag, Ubergang zur Vollbelastung nach radiologischer und klinischer Kontrolle nach 6 Wochen. Seit 2016 wurden 6 tibiale Avulsionsverletzungen (mittleres Alter 38 Jahre, Spanne 17–60 Jahre) in der beschriebenen Technik versorgt. Die postoperative radiologische Kontrolle zeigte keine Fragmentdislokation und eine vollstandige knocherne Einheilung nach 6 Wochen. Eine Irritation durch das verwendete Material wurde bis 6 Monate postoperativ nicht beobachtet. Keine Wundinfektion, Thrombose und postoperative Arthrofibrose im Verlauf. Keine Revisionen. In einem aktuellen Review zeigt die arthroskopische Versorgung im Vergleich mit einer offenen Versorgung leicht hohere objektive und subjektive Ergebnisse. Die Arthrofibroserate in der arthroskopischen Gruppe war leicht erhoht. In 7 von 18 eingeschlossenen Studien mit offener Fixation werden auch Nahte als Versorgung mehrfragmentarer Avulsionsfrakturen angefuhrt. Gerade in diesen Fallen scheint die beschriebene Fadenankertechnik sinnvoll.

Acute meniscus repair in young athletes is always a challenge due to the long rehabilitation process and time to return to sport (RTS). The purpose was to investigate signal alterations in short-term follow-up after acute meniscus repair on specific magnetic resonance imaging (MRI) scan sequences. It was hypothesized that (1) MRI signal changes over the first postoperative healing phase and represent a continuous healing process and (2) meniscus healing properties correlates with clinical outcomes and RTS. Young athletes with traumatic meniscus lesion and arthroscopic meniscus repair within 6 weeks and available preoperative MRI were enrolled. Clinical examination, outcome scores (IKDC, KOOS, Lysholm Score, Tegner activity score) and RTS were surveyed preoperatively and 6 and 12 weeks and 6 months after surgery. Radiological follow-up examinations were performed 2, 4, 6, 12 weeks and 6 months after operation using a 3T-MRI. Evaluation was based on ISAKOS meniscus classification system, meniscus healing were classified according to Henning’s criteria. At final follow-up (FU) 30 patients (28 month, 2 week) with a total of 35 meniscus tears (19 medial, 16 lateral) were included. Clinical scores improved significantly after surgery: IKDC Score (preOP: 39.4 ± 18.5, final FU: 78.8 ± 15.3) KOOS (preOP: 45.7 ± 22.1, final FU: 82.7 ± 12.5) and Lysholm Score (preOP: 42.8 ± 23.7, final FU: 84.4 ± 13.8) (p

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.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.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.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 IV.

Background While supraspinatus atrophy can be described according to the system of Zanetti or Thomazeau there is still a lack of characterization of isolated subscapularis muscle atrophy. The aim of this study was to describe patterns of muscle atrophy following repair of isolated subscapularis (SSC) tendon. Methods Forty-nine control shoulder MRI scans, without rotator cuff pathology, atrophy or fatty infiltration, were prospectively evaluated and subscapularis diameters as well as cross sectional areas (complete and upper half) were assessed in a standardized oblique sagittal plane. Calculation of the ratio between the upper half of the cross sectional area (CSA) and the total CSA was performed. Eleven MRI scans of patients with subscapularis atrophy following isolated subscapularis tendon tears were analysed and cross sectional area ratio (upper half /total) determined. To guarantee reliable measurement of the CSA and its ratio, bony landmarks were also defined. All parameters were statistically compared for inter-rater reliability, reproducibility and capacity to quantify subscapularis atrophy. Results The mean age in the control group was 49.7 years (± 15.0). The mean cross sectional area (CSA) was 2367.0 mm2 (± 741.4) for the complete subscapularis muscle and 1048.2 mm2 (± 313.3) for the upper half, giving a mean ratio of 0.446 (± 0.046). In the subscapularis repair group the mean age was 56.7 years (± 9.3). With a mean cross sectional area of 1554.7 mm2 (± 419.9) for the complete and of 422.9 mm2 (± 173.6) for the upper half of the subscapularis muscle, giving a mean CSA ratio of 0.269 (± 0.065) which was seen to be significantly lower than that of the control group (p

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

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

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

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

The purpose of this study was to evaluate the clinical and radiological outcomes of acute posterior cruciate ligament (PCL) lesions in multiple injured knees that were surgically treated with internal bracing. Acute complete PCL lesions in multiple injured knees with subsequent internal-bracing treatment within 21 days between 2014 and 2016 were eligible for inclusion. At final follow-up, patients were assessed with Tegner, Lysholm, and IKDC scores. PCL stability and healing were verified with KT-2000, stress radiography and magnetic resonance imaging (MRI). Fourteen patients [mean age 37.4 (± 17.8; SD) years] were evaluated after a mean follow-up of 19.9 (± 7.7; SD) months. Thirteen patients suffered complete lesions of the PCL with concomitant ligamentous injuries (Schenck I: six cases, Schenck III M: five cases, Schenck IV N: one case, Schenck V: one case). Median Tegner, mean Lysholm and mean IKDC scores at follow-up were 4 (2–7; interquartile range), 69.1 (± 16.6; SD) and 68.9 (± 18.1; SD) respectively. Posterior translation averaged 5.8 (± 2.2; SD) mm with the KT 2000 and stress radiography showed a mean posterior tibial translation of 5.5 (± 4.1; SD) mm in the side to side comparison. MRI showed adequate PCL healing. Internal bracing as treatment for acute PCL ruptures in multiple injured knees showed adequate restoration of posterior tibial translation in a single-centre study including 14 cases. IV.

Behandlung einer persistierenden anterolateralen Kniegelenksinstabilitat. Subjektive/objektive (Rotations‑)Instabilitat des Kniegelenks nach erfolgter (anatomischer) Rekonstruktion des vorderen Kreuzbandes (VKB). VKB-Reruptur inklusive spezieller Anforderungen (z. B. Hochleistungssport, Hyperlaxitat) Gonarthrose, Achsfehlstellungen oder additive Instabilitaten, die zusatzlich adressiert werden mussen; nichtanatomische VKB-Rekonstruktion (VKBR) mit persistierender Instabilitat (zuerst anatomische VKBR). Allgemeine Kontraindikationen (z. B. Infektionen), Reizzustand des Kniegelenks. Ruckenlagerung. Leicht bogenformige Schnittfuhrung im Bereich posterior und proximal des lateralen femoralen Epikondylus. Darstellung/Anzeichnen des Tractus iliotibialis. Proximales Ablosen und Armieren des Traktusstreifens. Unterminieren des lateralen Kollateralbands. Markieren des Isometriezentrums femoralseitig. Fixieren des Transplantats. Schichtweiser Verschluss. Hartrahmen-Kniegelenkorthese mind. 6 Wochen. Bewegungsumfang ab 1. postoperativem Tag: Flexion-Extension 90-0-0; 20-kg-Teilbelastung fur 2 Wochen postoperativ. Die aktuelle Literatur liefert Hinweise, dass eine anterolaterale Stabilisierung den Pivot-shift-Test sowie die Rerupturrate reduziert. Basierend auf biomechanischen Arbeiten ist dabei eine Tenodese nach Lemaire der Rekonstruktion des anterolateralen Ligaments vorzuziehen. Entscheidend ist jedoch die isometrische Bohrkanalplatzierung bzw. die Fixation in tibialer Neutralrotation mit geringer Transplantatspannung. Indikationen einer anterolateralen Stabilisierung sind VKB-Rupturen mit einem drittgradigen Pivot-shift bzw. Revisionsfalle oder persistierende anterolaterale Instabilitaten nach anatomischer VKBR.

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

Zusammenfassung Rupturen des vorderen Kreuzbandes fuhren zu einer anterolateralen Rotationsinstabilitat. Diese anterolaterale Rotationsinstabilitat kann trotz anatomischer vorderer Kreuzbandplastik aufgrund diverser Risikofaktoren bestehen bleiben. In ausgewahlten Fallen kann zusatzlich zu einer vorderen Kreuzbandplastik eine laterale extra-artikulare Stabilisierung zur Behandlung der anterolateralen Rotationsinstabilitat durchgefuhrt werden. Eine gangige Technik ist dabei die modifizierte laterale extra-artikulare Stabilisierung nach Lemaire. In diesem Artikel werden die Technik sowie potentielle Indikationen einer solchen Stabilisierung erlautert.

To investigate the stabilizing effect of a lateral meniscus posterior root repair in an ACL and root deficient knee. The hypothesis of the current study was that a sequential transection of the posterior root and the meniscofemoral ligaments in an ACL-deficient knee increases rotational instability, and conversely, a repair of the meniscus root reduces the internal tibial rotation. Therefore, eight human knee joints were tested in a robotic setup (5 N m internal torque, 50 N m anterior translation load). Five conditions were tested: intact, ACL cut, ACL cut + lateral meniscus posterior root tear (LMRT), ACL cut + LMRT + transection of the MFL and ACL cut + lateral meniscus root repair. The angles of internal tibial rotation as well as anterior tibial translation were recorded. Transection of the lateral meniscus posterior root increased the internal tibial instability as compared to the ACL-insufficient state. A significant increase was detected in 60° and 90° of flextion. Sectioning of the meniscofemoral ligament further destabilized the knees significantly at all flexion angles as compared to the ACL-deficient state. Even in 30°, 60° and 90° a significant difference was detected as compared to the isolated root tear. A tibial fixation of the lateral meniscus root reduced the internal tibial rotation in all flexion angles and led to a significant decrease of internal tibial rotation in 30° and 90° as compared to the transection of the root and the MFL. The anterior tibial translation was increased in all conditions as compared to the native state. A lateral meniscus root repair can reduce internal tibial rotation in the ACL-deficient knee. To check the condition of the lateral posterior meniscus root attachment is clinical relevant as a lateral meniscus root repair might improve rotational stability.

Trotz anatomischer vorderer Kreuzbandplastik leiden bis zu 15 % der Patienten unter persistierender anterolateraler Rotationsinstabilitat. Pradisponierende Faktoren sind neben Verletzungen des anterolateralen Komplexes ein erhohter tibialer Slope, Meniskuspathologien, allgemeine Hyperlaxitat sowie chronische vordere Kreuzbandinsuffizienzen. Um persistierende anterolaterale Rotationsinstabilitaten zu therapieren, bietet sich in ausgewahlten Fallen eine laterale extraartikulare Stabilisierung an. Diese kann auch in Kombination mit einer vorderen Kreuzbandplastik erfolgen. Neben der isolierten Rotationskontrolle konnen solche Stabilisierungen die Rerupturrate von vorderen Kreuzbandplastiken reduzieren. Eine gangige Technik ist dabei die modifizierte anterolaterale Stabilisierung nach Lemaire, welche in diesem Artikel beschrieben wird. Zusatzlich werden Tipps gegeben und Komplikationen erlautert.

Zusammenfassung Meniskusrisse konnen schwerwiegende Folgen in Bezug auf die Druckverteilung und die Stabilitat des Kniegelenkes haben. Gerade Sportler haben ein Risiko, traumatische Meniskusrisse zu erleiden. Die Wiederherstellung der Meniskusfunktion ist Ziel der operativen Behandlung und erfolgt bei traumatischen Radiarrissen, Rampenlasionen des Innenmeniskus und Wurzelverletzungen des Innen- und des Ausenmeniskus. Dieser Artikel beschreibt die Behandlung der genannten akuten Meniskusrisse.

Kniegelenkstraumen mit einer Ruptur des hinteren Kreuzbandes treten haufig bei jungen, aktiven Patienten auf. Neben einer bestmoglichen Operation sind eine gezielte Rehabilitation und gute interdisziplinare Zusammenarbeit entscheidend fur den Therapieerfolg.

Verlagerung der Traglinie des Beins nach zentral durch Offnen einer metaphysaren Osteotomie am lateralen distalen Femur. Femoral basierte Valgusfehlstellung und symptomatische unikompartimentelle laterale Gonarthrose, laterale Hyperkompression, Knorpeltherapie im lateralen Kompartiment, Meniskusersatz im lateralen Kompartiment, mediale Instabilitat durch lateralen Schub („Valgus-Thrust“), Rekonstruktion des medialen Kollateralbandapparats, Patellainstabilitat und/oder Maltracking. Fortgeschrittene Knorpelschadigung (> Grad 2) oder Z. n. subtotaler Meniskektomie des medialen Kompartiments, Alter > 65 Jahre (relativ), Nikotinabusus, Body-Mass-Index > 30, Flexionskontraktur > 25°, Korrekturen mit Osteotomiespalt > 10 mm bei angeborener Deformitat, entzundliche oder infektiose Gelenkerkrankungen, fortgeschrittene Osteoporose. Lateraler Zugang zum distalen Femur; biplanare Osteotomie (frontale + axiale Osteotomie); graduelles Aufspreizen der Osteotomie; Fixation mittels winkelstabiler Plattenosteosynthese. Keine Einschrankungen des Bewegungsumfangs, Teilbelastung mit 20 kg fur 2 Wochen, anschliesend beschwerdeadaptierte Aufbelastung. Bei Patienten mit unikompartimenteller lateraler Gonarthrose kann nach varisierender distaler Femurosteotomie von einer durchschnittlichen Zunahme um 20–30 Punkte in funktionellen Scores und einer mittleren Uberlebensrate von 80 % nach 10 Jahren ausgegangen werden. Die durchschnittliche Komplikationsrate liegt bei 9 %.

Wurzelverletzungen der Menisken sind schwerwiegend und fuhren zu einer erhohten Drucksteigerung im betroffenen Kompartiment. Daruber hinaus konnen sie destabilisierend auf das Kniegelenk wirken. Die Kenntnis dieser speziellen Meniskusverletzungen und ihrer verschiedenen Atiologien konnen die Wahrnehmung fur diese Verletzungen erhohen und zu einer Verbesserung der Versorgung beitragen. Dieser Artikel bietet eine Ubersicht uber die Anatomie, Biomechanik, Verletzungsatiologie sowie mogliche Versorgungsmoglichkeiten.

Isolierter Ersatz der Trochleaoberflache mit Inlay-Prothese, ohne die komplexe Biomechanik des femoropatellaren Gelenks zu verandern. Symptomatisch isolierte femoropatellare Arthrose oder osteochondrale Lasionen, erfolglose konservative Therapie, ausgeschlossene Indikation zu knorpelregenerativen Verfahren. Keine oder kombiniert korrigierte ligamentare Instabilitat, femorotibiale und femoropatellare Fehlstellung. Symptomatische femorotibiale Arthrose, aktive Infektionen, rheumatoide Arthritis, Kniegelenksteife. Zuerst erfolgt die Messung der koronaren und sagittalen Form der Trochlea, um die Implantatgrose zu bestimmen. Der zweite Schritt umfasst das zentrale Abfrasen des geschadigten Knorpels und das Anlegen eines Implantatlagers mit einem Fuhrungsblock. Wichtig ist, dass das Abfrasen auf Knorpelniveau abschliest, um spater ein stufenfreies Einbringen der Trochleakomponente zu ermoglichen. Danach wird eine konische Fixationsschraube in das Femur eingebracht, die sicher mit der trochlearen Prothese verbunden wird. Dabei schliest die Prothese mit dem Knorpelniveau ab. Die passive Beweglichkeit ist von Anfang an freigegeben. Abhangig von der Schmerz-, Schwell- und Ergussneigung erfolgt bis zur 2. postoperativen Woche die Teilbelastung mit 20 kg. Danach wird die Belastung mit 20 kg pro Woche erhoht. In einer prospektiven Studie zeigten 29 Patienten (mittleres Alter 42 Jahre) mit einer Inlay-Prothese 2 Jahre postoperativ signifikante Verbesserungen des WOMAC-, IKDC- und VAS-(Schmerz-)Score im Vergleich zum praoperativen Zeitpunkt (p < 0,05). Im Gegensatz zur Onlay-Prothese kam es mit einer Inlay-Prothese zu keinem Fortschreiten der femorotibialen Arthrose. Dies kann durch das Vermeiden eines „Overstuffings“ und somit durch eine verbesserte Gelenkkinematik bedingt sein.

Die akute hochgradige mediale Instabilitat erfordert insbesondere im Fall multiligamentarer Knieverletzungen eine operative Versorgung. Dabei bedingt die Risslokalisation die Versorgungsart. Eine direkte Ankerfixation tragt zu einem gesicherten Band-Knochen-Kontakt bei. Intraligamentare Risse sollten genaht werden. Eine zusatzliche Sicherung der genahten Strukturen kann durch ein „internal brace“ erreicht werden.

Purpose To compare clinical and radiologic results of primary anterior cruciate ligament (ACL) suture anchor repair and microfracturing with anatomic ACL single-bundle reconstruction in patients with acute proximal ACL avulsion tears. Methods Between January 2010 and December 2013, 420 patients underwent ACL treatment. Forty-one patients were included in this study. The inclusion criteria were as follows: unilateral acute proximal ACL rupture, concomitant meniscus lesions, no previous knee ligament surgery, and no additional ligament injuries or absence of ligament injury of the contralateral knee. Preoperative magnetic resonance imaging confirming a proximal avulsion tear of the ACL was required. Patients had to undergo surgical treatment within 6 weeks after injury. Follow-up examination included Lachman and pivot-shift testing, KT-1000 measurement, and the International Knee Documentation Committee score. Results At a mean follow-up of 28 months (range, 24 to 31 month), 20 patients in each group were available. A mean KT-1000 arthrometer result of less than 3 mm indicated stability in all patients ( P = .269). Three patients had a 1+ Lachman test ( P = .072) and 4 patients had a 1+ pivot-shift test in the ACL repair group ( P = .342). The International Knee Documentation Committee score results did not differ significantly ( P > .99), but there was a significant correlation between poor results and failure rate ( P = .001) in the refixation group. The failure rate was 15% in the ACL refixation group and 0% in the reconstruction group ( P = .231). Magnetic resonance imaging confirmed homogeneous signal and proper ACL position in 100% of patients in the control group and 86% in the ACL repair group. Conclusions Proximal refixation of the ACL using knotless suture anchors and microfracturing restores knee stability and results in comparable functional outcomes to a control group treated with single-bundle ACL reconstruction. The results suggest that refixation of the ACL is a feasible treatment option in selected patients. Level of Evidence Level III, case-control study.

Proximal hamstring tendon avulsions lead to a significant loss of strength and a functional deficit of the respective lower limb and surgery is the recommended treatment. Only little is known about the clinical outcomes and complications when comparing acute and chronic management as well as partial and complete tears. Therefore, the purpose of this study was to investigate the clinical results and the complication rate of patients after surgical treatment of proximal hamstring tendon injuries. It was hypothesized that surgical treatment of an acute proximal hamstring avulsion would lead to a superior clinical outcome with a low complication rate and high return to sports rate compared to chronic cases and partial avulsions. Patients who underwent proximal hamstring tendon repair between 2008 and 2015 were retrospectively evaluated with a minimum follow up of 2 years. Outcome measurements were obtained by means of Lysholm score, Harris Hip Score, Visual Analog Scale, and Tegner Activity Scale. Return to sports (RTS) rate was determined. Postoperative adverse events were recorded and complications reported. Patients’ outcomes were compared between acute/chronic repair and partial/complete injury patterns. Ninety-four of 120 (78.3%) were available for final assessment at a mean follow-up of 56.2 ± 27.2 months. Clinical outcome measures were excellent and did not differ between the treatment groups or between the different injury patterns. RTS was achieved by 86.2% of the patients and was significantly superior after acute treatment (p

Aims and Objectives: Tibial posterior cruciate ligament (PCL) avulsion fractures require surgical fixation in order to provide primary stability and adequate bone healing. Small fragments are common and comprise the risk to fracturing during screw fixation. Therefore, a suture-bridge configuration was developed to fixate small and multifragment fractures without the need of fragment drilling. The purpose of this study was to analyze the biomechanical properties of the suture-bridge technique compared to a well-established transtibial cortical suspension technique concerning cyclic elongation, stiffness and ultimate failure load. It was hypothesized that the suture bridge technique shows lower cyclic elongation and higher load to failure force compared to a cortical suspension button fixation. Materials and Methods: Nine fresh-frozen human cadaveric knees were biomechanically tested using an industrial testing machine (Zwick/Roell Amsler HC 10, Ulm). A standardized bony avulsion fracture (15 x 10 x 4 mm) of the tibial PCL insertion was generated. Two different techniques were used for fixation: A) 4x suture-bridge configuration (3 SwiveLock anchors, FiberTape, Arthrex Inc.) and B) 5x transtibial cortical suspension button fixation (FiberTape, Arthrex Inc). Cyclic loading was applied in 90° of flexion 500 times (10 to 100 N) to determine elongation, initial stiffness and load to failure. Students t-test for unpaired samples were used to calculate the difference of means (SPSS statistics software version 21). Statistical significance was set at a p value of < 0.05. Results: Suture-bridge technique resulted in a significant lower elongation (4.5 ± 2.9 mm) than transtibial cortical suspension button technique (11.9 ± 3.1 mm, pConclusion: The novel PCL suture-bridge technique provides a significant lower construct elongation during cyclic loading and a trend towards higher load to failure in comparison to cortical suspension button fixation. As a clinical consequence, suture-bridge technique should be considered to fix small PCL avulsion fractures at the tibial insertion site.

Arthroscopic partial meniscectomy of medial meniscus tears and varus alignment are considered independent risk factors for increased medial compartment load, thus contributing to the development of medial osteoarthritis. The purpose of this biomechanical study was to investigate the effect of lower limb alignment on contact pressure and contact area in the knee joint following sequential medial meniscus resection. It was hypothesized that a meniscal resection of 50% would lead to a significant overload of the medial compartment in varus alignment. Eight fresh-frozen human cadaveric knees were axially loaded with a 750 N compressive force in full extension with the mechanical axis rotated to intersect the tibia plateau at 30%, 40%, 50%, 60% and 70% of its width. Tibiofemoral mean contact pressure (MCP), peak contact pressure (PCP), and contact area (CA) of the medial and lateral compartment were measured separately using pressure-sensitive films (K-Scan 4000, Tekscan) in four different meniscal conditions, respectively, intact, 50% resection, 75% resection, and total meniscectomy. Medial MCP was significantly increased when comparing the intact meniscus to each meniscal resection in all tested alignments (p

Background: Degenerative medial meniscal tears and subsequent partial meniscal resection compromise meniscal function and lead to an overload of the medial compartment. In addition, lower limb alignment plays a key role in load distribution between the medial and lateral knee compartments, and varus alignment is a potential risk factor for medial osteoarthritis. Purpose/Hypothesis: The purpose of this biomechanical study was to investigate the effect of valgus and varus alignment on peak pressure and contact area in knees with concomitant horizontal medial meniscal tears and subsequent leaflet resection. It was hypothesized that varus alignment in combination with meniscal loss leads to the highest peak pressure within the medial compartment. Study Design: Controlled laboratory study. Methods: Six fresh-frozen human cadaveric knees were axially loaded using a 1000-N compressive load in full extension with the mechanical axis rotated to intersect the tibial plateau at 40%, 45%, 50%, 55%, and 60% of its width (TPW) to simulate varus and valgus alignment. Tibiofemoral peak contact pressure and contact area of the medial and lateral compartments were determined using pressure-sensitive foils in each of 4 different meniscal conditions: intact, 15-mm horizontal tear of the posterior horn, inferior leaflet resection, and resection of both leaflets. Results: The effect of alignment on peak pressure (normalized to the neutral axis) within the medial compartment in cases of an intact meniscus was measured as follows: varus shift resulted in a mean increase in peak pressure of 18.5% at 45% of the TPW and 37.4% at 40% of the TPW, whereas valgus shift led to a mean decrease in peak pressure of 8.7% at 55% of the TPW and 23.1% at 60% of the TPW. Peak pressure changes between the intact meniscus and resection within the medial compartment was less in valgus-aligned knees (0.21 MPa at 60% TPW, 0.59 MPa at 50% TPW, and 0.76 MPa at 40% TPW). Contact area was significantly reduced after partial meniscal resection in the neutral axis (intact, 553.5 ± 87.6 mm2; resection of both leaflets, 323.3 ± 84.2 mm2; P < .001). This finding was consistent in any alignment. Conclusion: Both partial medial meniscal resection and varus alignment led to an increase in medial compartment peak pressure. Valgus alignment prevented medial overloading by decreasing contact pressure even after partial meniscal resection. A horizontal meniscal tear did not influence peak pressure and contact area even in varus alignment. Clinical Relevance: As a clinical consequence, partial meniscal resection should be avoided to maintain the original biomechanical behavior, and the mechanical axis should be taken into account if partial meniscectomy is necessary.

To restore the posterior stability of the knee after a tibial posterior cruciate ligament (PCL) avulsion with a suture-button construct.Acute solid and monofragment bony avulsion of the tibial PCL insertion.Chronic condition of avulsion fractures or posterior instability, multifragment avulsions, thin bone pieces, advanced knee osteoarthritis, high-grade soft tissue injury, infection.Supine position, all-arthroscopic treatment via posteromedial and posterolateral portal, arthroscopic visualization and fracture reduction, transtibial drilling with a cannulated 2.4 mm drill, reduction of the fragment via FiberTape™ and Dog Bone. Knotting of the tapes against an additional Dog Bone at the anterior aspect of the tibia. Intraoperative x‑ray.Knee extension brace with posterior tibial support for 6 weeks, 20 kg partial weight-bearing and restricted flexion up to 90° for 6 weeks, physiotherapy in prone position from the first postoperative day. Full weight bearing after x‑ray and clinical control after 6 weeks.Since 2016 eight tibial PCL avulsions were treated. In 6 patients a suture-bridge technique via a mini-open approach was performed due to a small or comminuted fracture fragment. In 2 patients an all-arthroscopic technique was performed. No complications. The all-arthroscopic technique requires a solid fragment and enables the surgeon to treat additional pathologies. In general, the arthroscopic technique makes the open posterior approach unnecessary. The arthroscopic techniques achieve slightly higher objective and subjective values compared to the open procedure, despite a higher rate of arthrofibrosis.

Laterale Meniskuswurzelablosungen treten gehauft zusammen mit Rupturen des vorderen Kreuzbands (VKB) auf. Als operative Therapie einer alleinigen lateralen Wurzelablosung hat sich die transtibiale Fixierung mittels Auszugsnahten etabliert. Bei der zeitgleichen Rekonstruktion einer VKB-Ruptur kann aufgrund der anatomischen Lagebeziehung der tibiale VKB-Bohrkanal fur die Auszugsnahte genutzt werden. Die Autoren berichten uber einen 43-jahrigen Patienten, welcher mittels VKB-Rekonstruktion und zeitgleicher Refixation der Ausenmeniskushinterhornwurzel des rechten Kniegelenks versorgt wurde. Drei Monate postoperativ stellte sich der Patient mit einem quietschenden Kniegelenk in der Sprechstunde vor. Bei der arthroskopischen Revision zeigte sich ein Versagen der Wurzelrefixation. Der Faden der Auszugsnaht war weit in das Gelenk disloziert und fur das Quietschphanomen verantwortlich. Die Verwendung des VKB-Bohrkanals fur die Auszugsnahte von Meniskuswurzelrefixationen ist eine effiziente Methode. Bei technischen Schwierigkeiten der tibialen Verankerung der VKB-Plastik mit Interferenzschrauben stellt ein separater Bohrkanal eine Alternative zur sicheren Verankerung der Auszugsnahte dar, um das Risiko eines versehentlichen Fadenrisses zu verhindern.

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. 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. All reconstructions showed a significant lower maximum load (p

To compare sagittal and coronal tibial slopes between anterior cruciate ligament (ACL) injured subjects with and without posterolateral meniscus root tear (PLRT). A chart review was conducted to identify patients with isolated ACL tears and patients with an associated PLRT. Patients with other concomitant injuries and patients who underwent surgery > 6 months after the injury were excluded. Magnetic resonance image data were used to compare the medial and lateral sagittal tibial slope (MTS and LTS), lateral-to-medial slope asymmetry (LTS–MTS), and coronal slope of the tibial plateau between both groups. Mean LTS and standard deviation (SD) of the control group were calculated, and a value of > mean + 1 SD was considered an abnormal LTS. Interobserver reproducibility was assessed by calculating interclass correlation coefficients (ICCs) of measurements independently obtained by two reviewers. Fifty-nine patients met the in- and exclusion criteria. Thirty nine (66%) had an isolated ACL tear and 20 (34%) had an associated PLRT. Interrater ICCs for LTS, MTS, and coronal slope were 0.930, 0.884 and 0.825, respectively, representing good to excellent interobserver reproducibility. Patients with a PLRT had significantly steeper LTS (8.0 ± 3.2 vs. 4.0 ± 2.0; p

Ein Jahr nach der Fusball-Weltmeisterschaft beleuchtet der nachfolgende Beitrag typische Schaden und Verletzungen durch diesen Sport. Welche Behandlungsoptionen gibt es, insbesondere nach Ruptur des vorderen Kreuzbandes? Wann kann nach der Operation wieder gekickt werden?

Wiederherstellung der Valgus- und A-P-Stabilitat bei Verletzungen des medialen Kollateralbandes (MCL) und der posteromedialen Gelenkecke. Akute drittgradige Instabilitaten des MCL. Ruptur des hinteren Schragbandes (POL) bei zeitgleichem Vorliegen einer Ruptur des hinteren Kreuzbandes (HKB) und/oder des vorderen Kreuzbandes (VKB). Multiligamentverletzung mit Beteiligung des MCL. Tibiale Avulsionsverletzung mit „Umschlagen“ der Kollateralbandfasern uber den Pes anserinus superficialis. Kniegelenknahe Infektion, ungenugender Weichteilstatus, partielle intraligamentare Rupturen (Grad I und II). Das Prinzip der Nahttechniken ist die Readaptation der zerstorten Strukturen des MCL und des posteromedialen Komplexes nach anatomischen Gesichtspunkten. Femorale und tibiale Avulsionsverletzungen werden mit Fadenankern refixiert. Intraligamentare Rupturen werden am Ort der Ruptur readaptiert und konnen mit neutralisierenden Rahmennahten uberbruckt werden. Die Naht des MCL und des posteromedialen Komplexes kann in Kombination mit einer Rekonstruktion des HKB und auch des VKB erfolgen. Postoperativ Orthesenbehandlung zur Vermeidung von Valgusstress, 10–20 kg Teilbelastung. 1.–3. Woche: 0–20–60° Extension/Flexion, 4.–6. Woche 0–10–90° Extension/Flexion, ab der 7. Woche freies Bewegungsausmas. Im Fall einer Kombinationsverletzung der posteromedialen Gelenkecke mit HKB-Ruptur muss die Nachbehandlung entsprechend angepasst werden (6 Wochen Ruhigstellung in Streckstellung mit Wadenpelotte, Bewegungsubungen nur in Bauchlage). Von 2010 bis 2013 erfolgten insgesamt 34 operative Versorgungen akuter medialer Instabilitaten. Dabei erfolgten entsprechend des Verletzungsmusters kombinierte oder auch isolierte Eingriffe. Innerhalb des Patientenkollektivs bestand bei 25 Patienten als zusatzliche Verletzung eine Ruptur des VKB und bei 13 Patienten eine Ruptur des HKB. Die Versorgung der Begleitverletzungen wurde in einigen Fallen primar durchgefuhrt, in einigen Fallen aber auch in einem Zweiteingriff. Die mediale Stabilitat war postoperativ bei allen Patienten verbessert. Drei Revisionen (Arthrolyse) erfolgten aufgrund einer Arthrofibrose.

BACKGROUND Decathlon consists of various track and field running, jumping and throwing events. This results in high physical demands and poor postural control may predispose athletes at a higher risk for injury. The purpose of this study was to measure and to show a relationship of different dynamic postural control tests in healthy professional decathlon athletes. METHODS The German top decathlon team (eight professional athletes, mean age±standard deviation (SD), 20.8±2.7 years; mean height±SD, 187.1±4.3 cm; mean weight±SD, 82.1±7.2 kg) was tested. Star Excursion Balance Test (SEBT) and three different single-leg-hop tests (SLHT) (single hop for distance [SLH], crossover hop for distance [COH], triple hop for distance [TH] were measured and correlated. RESULTS A significant correlation was evident between SLH and COH (r=0.861, P=0.003) and SLH and TH (r=0.908, P=0.001). The correlational analyses of SEBT revealed a significant relationship between the posteromedial and posterolateral direction of the SEBT (r=0.943, P

This study was performed to compare the clinical results of a minimally invasive technique for acute acromioclavicular (AC) joint dislocation repair with the traditional hook plate fixation. Forty-four patients with an acute (within 2 weeks after trauma) complete AC joint separation (35 male, nine female; median age 36.2 years, range 18–56) underwent surgical repair with either a minimally invasive AC joint repair or a conventional hook plate. Functional outcome was evaluated using the Constant-Murley Score (CMS), the TAFT score and the AC joint instability score (ACJI). Radiographic evaluation was performed with bilateral anterior–posterior (a.p.) stress and Alexander views. All patients were available after a median follow-up of 32 months (range 24–51). There were no significant differences in the mean CMS, Taft score and the ACJI between the two groups. The radiological assessment revealed no significant difference in the coracoclavicular distance. In both groups, a slight loss of reduction was observed. Periarticular ossification was seen in 11 patients of the minimally invasive AC joint repair and eight patients of the hook plate group but this did not affect the final outcome. Hook plates were removed after a median interval of 11.9 weeks (range 10–13). Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation. However, in the hook plate group a second operation is mandatory for plate removal. III.

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.

The purpose of this article was to demonstrate an anterior cruciate ligament (ACL) reconstruction technique using oval tunnels. Aim of this single bundle technique is to fit the footprint anatomy of the ACL as closely as possible. TECHNIQUE AND PATIENTS: The presented technique is a single bundle technique using a semitendinosus graft. For femoral tunnel placement, a specific medial portal aimer (Karl Storz, Tuttlingen, Germany) is used. Aiming and drilling of the femoral tunnel are performed via the medial portal. Oval tunnels are created by stepwise dilatation with ovally shaped dilatators. The position of the femoral tunnel is visualized and controlled with the arthroscope via the medial portal. For the tibial tunnel placement, a specific aimer was used as well. With this technique, 24 patients were operated and all intra- and postoperative complications were analyzed prospectively. The tunnel position was documented postoperatively by CT scan.There were no significant intra- and postoperative complications associated with the oval tunnel technique. The postoperative 3D CT scan revealed that all femoral and tibial tunnels were located within the area of the anatomical ACL insertions.This article presents an ACL reconstruction technique using oval dilatators and medial portal aimers to create oval tunnels. These oval tunnels match the insertion site anatomy much closer than round tunnels do.Level IV, case series.