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Background: Retears after rotator cuff repair (RCR) have been associated with poor clinical results. Meaningful data regarding the role of arthroscopic revision RCR are sparse thus far. Purpose/Hypothesis: To investigate results after arthroscopic revision RCR. We hypothesized that (1) arthroscopic revision RCR would lead to improved outcomes, (2) the clinical results would be dependent on tendon integrity and (3) tear pattern, tendon involvement, and repair technique would influence clinical and structural results. Study Design: Case series; Level of evidence 4. Methods: During a 40-month period, 100 patients who underwent arthroscopic revision RCR were prospectively enrolled in this multicenter study. Outcomes were evaluated preoperatively, at 6 months (6M), and at 24 months (24M) using the Constant score (CS), the Oxford Shoulder Score (OSS), and the Subjective Shoulder Value (SSV). Tendon integrity at 2 years was analyzed using magnetic resonance imaging. A total of 13 patients (13%) were lost to follow-up, and 14 patients (14%) had a symptomatic retear before the 24M follow-up. Results: All clinical scores improved significantly during the study period (CS: preoperative, 44 ± 16; 6M, 58 ± 22; 24M, 69 ± 19 points; OSS: preoperative, 27 ± 8; 6M, 36 ± 11; 24M, 40 ± 9 points; SSV: preoperative, 43% ± 18%; 6M, 66% ± 24%; 24M, 75% ± 22%) ( P < .01). At 2 years, a retear rate of 51.8% (43/83) and a surgical revision rate of 12.6% (11/87) were observed. Mean full-thickness tear size decreased from 5.00 ± 1.61 cm2 to 3.25 ± 1.92 cm2 ( P = .041). Although the Sugaya score improved from 4.5 ± 0.9 to 3.7 ± 1.4 ( P = .043), tendon integrity did not correlate with better outcome scores. Previous open RCR, involvement of the subscapularis, chondral lesions of Outerbridge grade ≥2, and medial cuff failure were correlated with poorer SSV scores at 2 years ( P≤ .047). Patients with traumatic retears had better CS and OSS scores at 2 years ( P≤ .039). Conclusion: Although arthroscopic revision RCR improved shoulder function, retears were frequent but usually smaller. Patients with retears, however, did not necessarily have poorer shoulder function. Patient satisfaction at 2 years was lower when primary open RCR was performed, when a subscapularis tear or osteoarthritis was present, and when the rotator cuff retear was located at the musculotendinous junction. Patients with traumatic retears showed better functional improvement after revision.

Background: The coronavirus disease 2019 (COVID-19) pandemic has impeded the treatment of elective shoulder patients all over the world. Owing to the constraints in personnel and operation theater capacities, many patients who should undergo planned surgeries could not receive medical care. In our study, we examined the status quo of elective shoulder arthroscopy during the pandemic in Germany. Methods: Using a nonprofit database, 40 shoulder units that performed the most arthroscopic rotator cuff repairs in Germany in 2018 were identified. Following a standardized protocol, the web pages of these units were screened, and their strategy for elective procedures during the COVID-19 pandemic was analyzed. Special emphasis was put on the use of new digital technologies. Results: At the time of the study, no unit had stopped scheduling appointments for elective shoulder patients because of the pandemic. Almost all units (97.5%) offered explicit information about COVID-19 and their strategies toward it. The possibilities of visiting patients in shoulder units varied owing to local restrictions. Two units (5%) offered digital consultations. Conclusion: At the time of the study, elective shoulder procedures could be planned and carried out at the largest centers in Germany. Local restrictions had a great influence on the organization of the procedure and hospital stay during the COVID-19 pandemic. Digital consultations were not available in every unit.

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.

Objective In this study, we hypothesized that standing and supine X‐rays lead to different preoperative planning results. Methods The present study included 168 pictures from 81 patients who were treated surgically with high tibial osteotomy (HTO) for varus deformity between January 2017 and February 2018. Each patient underwent whole leg X‐ray examinations in both standing and supine position. On both images, the following parameters were measured: degree of axis deviation (DAD), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), width of medial (MJS) and lateral joint space (LJS), and the correction angle (CA). The results were correlated with the patients’ age and body mass index (BMI). To analyze intra‐observer reliability, the same researcher, blinded to the previous measurements, remeasured all X‐rays from 10 patients 8 weeks after the initial measurements were carried out. Results While mLDFA (P = 0.075), mMPTA (P = 0.435), and MJS (P = 0.119) did not show any differences between the two modalities, LJS (P = 0.016) and DAD (P, In this study, we hypothesized that standing and supine X‐rays lead to different preoperative planning results in high tibial osteotomies. Indeed, we did find an influence of the imaging modality on planning results; however, these results were not influenced by body mass and age.

The subscapularis muscle is an important active stabilizer of the glenohumeral joint. For this radiological study, we investigated if its radiological integrity is affected after arthroscopic glenoid reconstruction. In the technique used, an autologous iliac crest graft is transported through the rotator interval, and the graft is fixed via an antero-inferior portal with compression screws. 3 women and 6 men (mean age 31 ± 9 years, min 21, max 46 years) who had a preoperative glenoid deficit of 23% ± 6% (min 13%, max 29%) were included. In a follow-up after an interval of 34 months (min 19, max 50), MRI scans were performed on both shoulders. With ITK-SNAP, a 3D reconstruction software, the volume of the subscapularis muscle in the injured and contralateral shoulder was measured. In addition, signal intensity ratios (PSI) (infraspinatus muscle / cranial subscapularis muscle and infraspinatus muscle / caudal subscapularis muscle) were analyzed and the width of the cranial and caudal portions as well as the length of the subscapularis muscle in the parasagittal plane were determined. The 3D volume showed no difference between operated and healthy shoulders (p = 0.07), neither did PSI ratios (infraspinatus muscle / cranial subscapularis muscle: p = 1.00, infraspinatus muscle / caudal subscapularis muscle: p = 1.00). In the parasagittal plane, length (p = 0.09) and cranial width (p = 0.23) did not differ. However, the width of the lower muscle was increased in injured shoulders (p = 0.02). In this cohort, no relevant volume loss could be found after arthroscopic glenoid reconstruction. However, a greater width of the lower muscle portion could be identified in the parasagittal plane as a possible indication of scarring.

OBJECTIVE Dynamic horizontal instability is considered to be the main reason for poor outcome after treatment for acromioclavicular (ac) joint instability. In this study, we describe a simple technique to quantify this pathology via sonography. METHODS Thirty-six shoulders from 18 patients with ac joint instabilities were examined using modified Alexander views and a standardized sonographic examination. On the Alexander views, overlap of acromion and clavicle (OLAC), glenoid center to posterior clavicle distance (GCPC), and lateral extension (LE) were measured. Afterwards, the results were analyzed and compared with sonography. Posterior translation of the clavicle and the difference of translation between healthy and injured shoulder were evaluated. RESULTS The mean age of the patients was 39 ± 14 years (range 19-61 years). We included 4 (22%) Rockwood type 3, 1 (6%) Rockwood type 4, and 13 (72%) Rockwood type 5 lesions. Four (22%) patients were female and 14 (78%) male patients. Posterior clavicle translation of the injured shoulder correlated strongly between OLAC and sonography (r = -0.514, P = .029), and the difference of translation between healthy and injured shoulder correlated very strongly between LE and sonography (r = 0.737, P

Background Arthroscopic glenoid reconstruction using autografts is an advanced procedure that requires experience and preparation. Knowledge about anatomic pitfalls is therefore important to establish well-positioned portals and prevent neurovascular damage. Methods We included 43 computed tomography scans from 43 patients. The distance between the tip of the coracoid process and a perpendicular line representing the anteroinferior glenoid was measured. From these results an anteroinferior working portal was designed, and the angulation needed for screw insertion to fixate a hypothetical graft was measured. In a second step, 9 patients underwent magnetic resonance imaging scans 34 ± 10 months after glenoid reconstruction, and the distance between the screw approach path and the neurovascular bundle was measured. Results In the analyzed scans, average defect size was 23%, and the coracoid process to the anteroinferior glenoid distance was 32 ± 7 mm. We thus hypothesized that a corridor 20 to 30 mm inferior to the coracoid process would be the ideal position for a working portal. Through this portal, 85% of screws could be applied with 0° to 30° angulation. When the postoperative scans were analyzed, the distance from the neurovascular bundle showed an average of 26 ± 6 mm for the superior screw and 21 ± 5 mm for the inferior screw. Conclusions The ideal distance between the coracoid process and an anteroinferior working portal is 32 mm. Having established the portal, instruments should not be inserted pointing in a medial direction of the coracoid process due to the proximity of the neurovascular bundle.

Introduction The fixation of the coracoid process onto the glenoid is an important step of the Latarjet procedure, and implant-associated complications are a relevant and severe problem. This study compares the fixation strength and failure mode of two biodegradable materials with stainless-steel screws. Methods 24 Fresh-frozen cadaveric scapulae were divided into three groups of equal size and received a coracoid transfer. Cadavers were matched according to their bone mineral density (BMD). In group 1, small-fragment screws made of stainless steel were used. In the second group, magnesium screws were used, and in the third group, screws consisted of polylactic acid (PLLA). A continuously increasing sinusoidal cyclic compression force was applied until failure occurred, which was defined as graft displacement relative to its initial position of more than 5 mm. Results At 5-mm displacement, the axial force values showed a mean of 374 ± 92 N (range 219–479 N) in group 1 (steel). The force values in group 2 (magnesium) had a mean of 299 ± 57 N (range 190–357 N). In group 3 (PLLA), failure occurred at 231 ± 83 N (range 109–355 N). The difference between group 1 (steel) and group 2 (magnesium) was not statistically significant (P = 0.212), while the difference between group 1 (steel) and group 3 (PLLA) was significant (P = 0.005). Conclusion Stainless-Steel screws showed the highest stability. However, all three screw types showed axial force values of more than 200 N. Stainless steel screws and PLLA screws showed screw cut-out as the most common failure mode, while magnesium screws showed screw breakage in the majority of cases. Evidence Controlled laboratory study.

Glenoid bone loss in recurrent anterior instability of the shoulder needs to be addressed to restore joint stability. Over the last years, several arthroscopic methods have been described to treat this condition. However, no clinical mid-term results have been presented for arthroscopic iliac crest bone grafting procedures. We included 32 patients with significant glenoid bone loss and repetitive dislocations of the shoulder who were treated in our shoulder unit with a previously described all-arthroscopic reconstruction technique. All patients filled out a questionnaire evaluating repetitive dislocations, consumption of pain medicine, Constant Score (CS, adapted to age and gender), activities of daily living (ADL), visual analogue scale for pain (VAS) as well as the Western Ontario Shoulder Instability Index (WOSI). Additionally, all complications were recorded. After a mean follow-up of 42 months, three traumatic dislocations had been observed. With an ADL of 25 points (95% CI 24–27), a WOSI of 71% (95% CI 65–76) and CS of 87 points (95% CI 82–92), our patients showed good functional results. The VAS result for pain was 2.1 (95% CI 1.5–2.6). No patient reported the regular usage of pain medicine related to the shoulder instability at final follow-up. The all-arthroscopic glenoid reconstruction using iliac crest grafts shows good functional results with a recurrence rate of 9%. At final follow-up 42 months after surgery, our patients showed low pain levels and acceptable complications.

The aim of this retrospective study was to analyse clinical and radiological outcome after medial patellofemoral ligament reconstruction (MPFLR) and tibial tuberosity medialisation (TTM) in patients with recurrent patellar instability. Thirty-five patients were included between 2008 and 2012. According to defined criteria such as tibial tuberosity-trochlear groove (TTTG) distance, hyperpression on the lateral patella facet and lateral retropatellar cartilage damage either MPFLR (group A) or TTM (group B) was performed: 18 patients underwent TTM, the other 17 patients underwent MPFLR. At a mean of 25.4 ± 9.7 (group A) and 35.2 ± 17.6 months (group B) patients were clinically and radiologically reviewed. Validated knee scores such as Kujala, Lysholm and Tegner score were evaluated. In both groups one patient reported of a non-traumatic patellar redislocation. Patients who underwent MPFLR (group A) had less pain postoperatively during activity according to the Visual Analogue Scale (group A: 2.0 ± 2.1 points, group B: 3.9 ± 2.3 points). Retropatellar cartilage damage increased in group B from grade 1 (range: 1–3) preoperatively to grade 2 (range 1–3) postoperatively (p > 0.05). All other clinically evaluated items, as well as the applied knee scoring systems, indicated no significant difference (p > 0.05) and displayed good to excellent results. MPFLR and TTM leed to good clinical results despite its own indications. For this reason—in selected cases—TTM may still be a suitable procedure for surgical treatment of patellar instability. However, patients treated by TTM (group B) revealed an increased retropatellar cartilage damage as well as significantly more pain during activity.

BACKGROUND: Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies.METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement.RESULTS: Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue).CONCLUSION: A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

Recurrent anterior instability of the glenohumeral joint is a demanding condition, especially in cases of glenoid bone loss. Various treatment options have been described, such as arthroscopic grafting techniques and the Latarjet procedure. In this study, the degree to which an arthroscopically applied iliac crest graft restores the glenoid anatomy was evalutated. Nine patients (three women and six men) with an average age of 31 ± 9 years (21–46 years) who were treated with an arthroscopic iliac crest graft technique were included in this study. After a mean follow up of 34 ± 10 months (19–50 months) after the procedure, MRI scans of both shoulders were performed and the glenoid width, Glenoid Index (GI), Pixel Signal intensity (PSI), thickness of the tissue covering the articular aspect of the graft, inclination, version, concavity and balance stability angle were measured. All scans showed the cultivation of tissue on the graft, which visually resembled the cartilage of the native ipsilateral glenoid. Additionally, reshaping of the graft to repair the glenoid configuration could be observed. Glenoid width (p = 0.022) and GI (p

In severe shoulder instability, chronic glenoid bone deficiency is a challenge for arthroscopic shoulder surgeons. This paper presents a new all-arthroscopic technique of iliac crest bone graft transfer for those patients. Transportation through the rotator interval and repositioning into the glenoid defect is achieved by use of a tracking suture, while fixation of the graft is performed by biodegradable or titanium double-helix screws. Overall, the feasibility and reproducibility of this new reconstruction technique in recreating the bony and soft tissue anatomy of the antero-inferior glenoid could be demonstrated. So far, preliminary outcomes of 24 patients operated on using this technique are promising. Level of evidence Case series with no comparison group, Level IV.

Background Glenoid bone loss in recurrent anterior shoulder instability is a challenging problem for shoulder surgeons, and knowledge about the anatomy of glenoid deficits is scarce. In this study, we tried to evaluate the pattern of this pathology. Methods Our analysis included 44 shoulders from 44 patients with recurrent anterior shoulder instability accompanied by a clinically relevant glenoid bone loss. The defect size, the localization of the inferior defect edge, and the defect angle were measured, and osseous landmarks were identified. An en face view on 2-dimensional computed tomography scans of each patient was fitted onto a template to create a deficit map for small ( 23%) defects. Results The study cohort consisted of 9 women and 35 men with a mean age of 33 ± 11 years at the date of the scan. The defect size and localization of the inferior defect edge showed significant differences between both groups, indicating a more posterior position of larger defects. The defect angle, however, showed no significant difference between small and large defects. Both groups showed a vertical defect pattern. Conclusion The osseous glenoid deficit in recurrent anterior shoulder instability shows a vertical pattern with no remarkable differences between small and large defects. This finding can influence biomechanical models as well as surgical reconstruction.

Hybrid fixation has been proposed to improve outcomes of anterior cruciate ligament (ACL) reconstructions. This study evaluated midterm outcomes after transfemoral graft fixation using either a conventional or a modified technique using additional bone plug augmentation (BPA) of the femoral tunnel aperture.Seventy-one consecutive patients undergoing ACL reconstruction using a quadrupled hamstring autograft with transfemoral graft fixation and tibial interference screw fixation were included. Of these, 56 patients could be followed up 61 months (range 52-69 months) after ACL reconstruction both clinically and by magnetic resonance imaging (group A, conventional technique, n = 34; group B, modified technique, n = 22). Anteroposterior (AP) laxity measurements and International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scoring were performed, while imaging included assessment of bone tunnel diameters, graft condition and graft filling at the femoral bone tunnel aperture.Patients with additional BPA had a significantly higher degree of graft filling at the femoral bone tunnel aperture (p = .0135) and 'healthier' grafts (p = .0495). They also tended to display less AP laxity difference in terms of mean differences and total patient numbers. Lysholm, IKDC and Tegner activity index scores and bone tunnel diameters were not significantly different.Additional BPA is an easy-to-perform, cheap and safe manoeuvre, which has the capacity to improve morphological and clinical outcomes at five year follow-up. However, femoral tunnel widening is unaffected by additional BPA.

Biodegradable transfemoral graft fixation devices used in anterior cruciate ligament (ACL) reconstruction have recently been reported to precociously lose structural integrity. This study investigated outcomes after ACL reconstruction using hamstring grafts and biodegradable transfemoral fixation at 5-year follow-up. The condition of both graft and fixation device was evaluated by magnetic resonance imaging (MRI) and related to clinical outcomes. In total, 85 patients on whom index ACL reconstructive surgery by means of a quadrupled semitendinosus–gracilis graft and biodegradable transfemoral fixation was performed were included in the study. Fifty-nine patients could be assessed by clinical and MRI examinations at a mean follow-up of 61 months (range, 52–69 months). Completely intact pins were found in 17 patients (29%), intact pins with delicate areas of resorption in 8 patients (14%), pin deformation in 5 patients (8%), pin fracture in 22 patients (37%) and pin migration in 3 patients (5%). In 40 patients (68%), pins had undergone degradation at the graft suspension point. Hamstring graft integrity and signal intensity scores were found to be significantly higher in patients with deformed, broken or dislocated pins as compared to patients with fully or mainly intact pins. Clinically, the mean side-to-side difference in anterior-posterior-laxity was 1.1 ± 1.6 mm, while Lysholm, IKDC and Tegner scores were 89 ± 11, 84 ± 14 and 4 (1–9). No statistically significant correlation was found between pin condition and clinical outcomes. Biodegradable fixation pins lose structural integrity in a way that suggests continuous loading of the pin/graft construct, thereby questioning osseous incorporation of the graft. This situation is clinically relevant in terms of improved graft condition. Retrospective case series, Level III.

Bizepssehneninstabilitaten sind selten und rein klinisch kaum zu sichern. Mit der MRT kann man meist die Diagnose stellen. Arthroskopisch ist die Stabilitatstestung mit Druck nach medial und lateral in jedem Fall notwendig. Therapeutisch sind Tenodese oder Tenotomie der Bizepssehne notwendig, Begleitlasionen sollten je nach Relevanz mitversorgt werden.

We examined the degree of retropatellar pain related to biomechanical factors of the implantation in 31 cases of GSB-endoprostheses without retropatellar alloarthroplasty, loosening or infection. Postoperative patella alta and lateralisation of the patella extended the retropatellar pain syndrom but not tibiaventralisation. These results indicate that certain unfavourable patella positions may be responsible for the retropatellar pain syndrom in patients with a GSB-endoprosthesis.

PROBLEM Despite the great progress in knee arthroplasty made within the previous decade the problem of patellar resurfacing is still unsolved. MATERIAL AND METHODS In a retrospective matched-pairs study in 62 patients with Natural Knee endoprostheses including one group with and another without patella resurfacing were compared. Results were assessed according to the American Knee Society Score and the patients subjective assessments. RESULTS At an average follow-up time 2 years there were no differences in the clinical findings and the patients subjective opinions between both patient groups. However, patients with rheumatoid arthritis and patella resurfacing showed significantly better results in both categories than those rheumatoid patients without patella resurfacing. CONCLUSION Summing our results up we cannot give a general advise towards the use of patella resurfacing in knee replacements. In patients with severe arthrosis of the femoro-patellar joint and in patients with rheumatoid arthritis, however, the patella replacement is considered to be the therapy of choice at our department.

There are different opinions on the duration of post-operative shoulder immobilisation following arthroscopic repair of labrum tears. Between 1993 and 1994 at our department arthroscopic repairs of the glenoid labrum as described by Habermeyer (15, 16) have been performed in 38 patients. In 20 of these patients postoperative treatment included immobilisation of the operated shoulder in a Gilchrist-bandage for 3 weeks, while in the remaining 18 patients this postoperative immobilisation period was decreased to only 1 or 2 weeks. Physiotherapy started the day after the operation, using a device for passive-motion exercises. The mean follow-up time of our examinations was 15.4 month. The mean score by Rowe rose significantly from 20.0 preoperatively to 82.6 at the follow-up examination. Results were excellent or good in 89.4% of all cases, new shoulder dislocations did not occur in any case. Patients having their shoulders immobilised for 3 weeks reached significantly higher Rowe-scores at our follow-up than those patients, whose shoulders were immobilised for only 1 or 2 weeks. Therefore, postoperative management following arthroscopic repair of labrum tears should include immobilisation of the operate shoulder for 3 weeks and an early start of passive-motion exercises.

Isolated patellofemoral osteoarthritis in the healthy middle-aged population is a challenging problem. Fifty-one knees in 50 patients with isolated patellofemoral osteoarthritis were treated by partial lateral facetectomy, lateral release, and medialization of the tibial tubercle. The minimum followup was 7 months (mean, 20.2 months; range, 7–32 months). Preoperative radiographs showed Ahlback Grades III and IV lateral patellofemoral joint space narrowing. The mean age of the patients was 60.1 years (range, 46–81 years). The subjective outcome was based on the WOMAC and the McCarroll score. Posteroanterior flexion weightbearing views, lateral views, and 45° axial views were taken. According to the WOMAC score, the scores improved considerably by 2.34 points with respect to pain and by 1.63 points with respect to function. The Insall-Salvati index decreased considerably but still remained in the physiologic range. The majority of these patients experienced improvement in their patellofemoral symptoms. However, the clinical outcome was not better in comparison to other surgical procedures. After the short followup, we would not recommend combined lateral facetectomy, lateral release, and medialization of the tibial tubercle until longer results are available. Level of Evidence: Level IV Therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic rotator cuff reconstruction (ARCR) is a challenging operative procedure in the treatment of symptomatic cuff tears. The literature does not consistently report on surgical complications after this procedure.

Traumata stellen die haufigste Ursache fur die Einsteifung des Ellbogengelenks dar. Entsprechend der Neutral-Null-Methoden wird die Beweglichkeit von Extension/Flexion von 0°-30°-130° als „functional arc“ beschrieben, eine Beweglichkeit, die im Alltag benotigt wird. In den vergangenen Jahren hat sich zunehmend die arthroskopische Technik der Arthrolyse durchgesetzt. Diese sollte in Seiten- oder Bauchlagerung des Patienten erfolgen, um Zugang zum posterioren Gelenkbereich zu erhalten.

Purpose: The incidence and progression of osteoarthritis over a time period of 35 years following anterior cruciate ligament (ACL) disruption in high-level athletes has not been clearly determined. Our study examined this. Type of Study: Retrospective cohort clinical study. Methods: Following a central guideline, between March 1963 and December 1965, all 19 athletes in the Olympic program of former East Germany who sustained an ACL injury were treated without reconstruction. In a retrospective cohort study, the clinical results were evaluated for all patients from 1975 and 1985 and for 17 of the 19 patients in 2000; 18 of the 19 patients were examined arthroscopically in 1985. Results: All patients were able to return to sports after a period of 6 to 14 weeks. Ten years after the injury, meniscectomy had to be performed in 15 of the 19 patients (79%). The medial meniscus was affected in 13 patients (68%) and the lateral in 7 (37%); 20 years after the injury, meniscectomy was necessary in 18 of the 19 patients (95%). In 1985, in 18 of the 19 knees, arthroscopy was performed and 13 patients (68%) had a grade 4 chondral lesion. Ten total knee replacements had to be performed until the end of the year 2000. Conclusions: We conclude that, despite the possibility of return to high-level activity with a definitive unstable knee, this will lead in 95% of cases to meniscal and cartilage damage over the next 20 years. In addition, cartilage damage and progressive osteoarthritis will occur and patients will have a high risk of becoming a candidate for further total joint replacement. Level of Evidence: Level IV.

Biodegradable implants are frequently used for meniscus repair. Articular cartilage damage has been reported recently after meniscus repair with biodegradable implants. The aim of the study was to investigate the meniscofemoral contact pressure at the posterior horn of the medial and lateral meniscus after repair of bucket-handle lacerations.Specimens were mounted in a materials testing machine (Bionix 858, MTS) which was equipped with a load cell. The quadriceps tendon was attached to a hydraulic cylinder, and knee motion was controlled via tension of the quadriceps tendon. A piezo-resistive system (Tekscan, Boston, MA, USA) measured the meniscofemoral contact pressure. Five different types of biodegradable implants (Arrow, Dart, Fastener, Stinger and Meniscal Screw) and horizontal suture (no. 2 Ethibond) were tested. The knee was extended from 90 degrees of flexion to 0 degrees under a constant load of 350 N due to adjustment of the tension force of the quadriceps tendon. The femorotibial pressure and contact area were recorded at 0 degree, 30 degrees, 60 degrees and 90 degrees of flexion.The meniscofemoral pressure did not increase after meniscus repair with biodegradable implants or sutures. The meniscofemoral peak pressure at the posterior horn was 1.46+/-1.54 MPa in the medial compartment and 1.08+/-1.17 MPa in the lateral compartment at full knee extension. The meniscofemoral pressure increased significantly in both compartments with knee flexion from 0 degree to 90 degrees.Biodegradable implants for meniscus repair do not affect the meniscofemoral pressure. However, there remains a risk of damage to the cartilage when barbed implants are used. If the implant is not entirely advanced into the meniscus, the sharp head or some of the barbs at the column of the implant may come into direct contact with the articular cartilage of the femoral condyle or tibial plateau. The authors presume that incorrect positioning of the implant seems to be the major reason for cartilage damage.

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Abstract Besides the Bankart lesion as the most common injury pattern after shoulder dislocation, the anterior or posterior detachment of the inferior capsule from the humeral head has come into the focus of shoulder surgery. As it is a rare lesion, the surgeon has to be aware of the existence of a so-called HAGL lesion. The combination of a symptomatic chronic shoulder instability or failed repair with a high number of dislocations and a typical MRI (Magnetic Resonance Imaging) with a J-shaped form of the inferior capsule leads to the possible diagnosis of HAGL which can be verified during arthroscopy and in most cases treated simultaneously with reattaching the capsule to the humeral bone using small bone anchors. Open surgery is equally used. The operation is technically demanding, and the small series published in the literature promise good clinical results. Acute HAGL lesions have a high rate of healing potency and can therefore be treated conservatively.

With the introduction of arthroscopy most of the surgeon have changed their technique in ACL-reconstruction from open to arthroscopically performed techniques. Several new techniques have been developed in the past, including new fixation devices and different grafts. The cruciate ligament reconstruction comprises a composition of both, the graft and the fixation to the bone. Well accepted autografts are the patellar midthird, the semitendinosus/gracilis or the quadriceps tendon. In special cases allografts are alternatives. The fixation can cause failure due to overstrain or creep during the postoperative period of healing. Considering their biomechanical properties, cruciate ligament reconstruction should aim for a graft behavior comparable with the native cruciate ligament. Results gained from basic science and clinical studies are reviewed in the following article.

Das Ziel der vorliegenden prospektiven randomisierten Studie ist die klinische Evaluation der 2-Jahres-Ergebnisse nach arthroskopischer Ersatzplastik des vorderen Kreuzbands unter Verwendung des mittleren Patellarsehnendrittels oder der Semitendinosussehne. Methodik. 20 Patienten wurden in arthroskopischer transtibialer Technik mit einem mittleren Patellarsehnentransplantat (BTB-Gruppe) mit 20 Patienten mit gedoppelter Semitendinosussehne (SET-Gruppe) postoperativ untersucht. Die klinische Evaluation erfolgte praoperativ und zum Zeitpunkt der Nachuntersuchung mittels IKDC, Tegner-Aktivitatslevel sowie dem retropatellare Schmerzscore nach McCarroll. Zur Bestimmung der a.-p.-Translation im Seitenvergleich diente der KT-1000. Ergebnisse. Bezuglich des Gesamtergebnisses im IKDC erreichten in der SET-Gruppe 80% und in der BTB-Gruppe 50% der Patienten gute oder sehr gute Ergebnisse. Die Differenz der a.-p.-Translation im Seitenvergleich betrug in der BTB-Gruppe 1,6 mm (−2–4 mm) und in der SET-Gruppe 2,7 mm (0–7mm) (p

Das Ziel der vorliegenden Arbeit bestand darin, unter Verwendung eines Tiermodells weitere Informationen zu unterschiedlichen Verankerungstechniken von Hamstring-Sehnen bei der vorderen Kreuzbandplastik hinsichtlich der maximalen Zuglast, Elongation und Steifigkeit zu gewinnen. Methode: Funf verschiedene Fixationstechniken wurden untersucht. Die BTB-Gruppe beinhaltete die Verankerung des Lig. patellae mittels Titan-Interferenzschraube, die BIO-Gruppe die Verankerung der freien Sehen mittels Polylactatschraube, die SAN-Gruppe die Verwendung einer Sandwichtechnik mit Titan-Interferenzschraube, die STA-Gruppe die Verwendung von 2 Ligamentklammern und die FAD-Gruppe die Fadenverankerung mittels No.-6-Ethibond. Die Messungen erfolgten mit einer Universalprufmaschine Typ Tiratest 2425 ® , die mit einer Zuggeschwindigkeit von 50 mm/min arbeitete. Ergebnisse: Die signifikant hochste Zuglast zeigte die BTB-Gruppe mit 718 ± 219 N (p < 0,01), gefolgt von der BIO-Gruppe (460 ± 116 N) und der STA-Gruppe (436 ± 52 N). Hinsichtlich der Steifigkeit bestanden keine Unterschiede zwischen der BTB- und BIO-Gruppe. Die signifikant geringste Steifigkeit boten die SAD-Gruppe und FAD-Gruppe (p < 0,05). Die Sandwichtechnik entsprach nicht der Stabilitat, die fur die Fixation von Kreuzbandtransplantaten erforderlich ist. Schlussfolgerungen: Fur die Verankerung der Hamstring-Sehnen empfehlen wir neben der Verwendung der Biolactatschraube eine zusatzlich Sicherung mittels Ligamentklammer oder Pollerschraube uber Ethibondfaden.

Ziel der Studie war es zu untersuchen, in welchem Ausmas ein Defizit der willkurlichen Aktivierbarkeit des M. quadriceps bei schweren Knieverletzungen vorliegt und welchen Einfluss ein Aktivierungsdefizit auf die Muskelfunktion hat. Untersucht wurden 33 mannliche Patienten nach Rupturen des vorderen Kreuzbandes (VKB) mit Begleitverletzungen der Kniegelenke im Vergleich zu 22 Patienten mit einer isolierten VKB-Ruptur und einem altersangepassten gesunden Kontrollkollektiv. Mit einer sensitiven Twitch-Interpolationsmethode wurde die isometrische Maximalkraft des M. quadriceps und die Fahigkeit der Probanden, die Quadrizepsmuskulatur willentlich zu aktivieren, bestimmt. Die Patienten mit VKB-Ruptur und Begleitverletzungen hatten eine signifikant schlechtere Aktivierbarkeit der Quadrizepsmuskulatur sowohl auf der verletzten (78,8±2,09%, mean±SEM) als auch gleichermasen auf der gesunden Seite (78,9±1,91%) im Vergleich zu dem Kontrollkollektiv und zu der Gruppe mit isolierter VKB-Ruptur. Der gemessene Kraftverlust beruhte auf der gesunden Seite alleine auf das beschriebene Aktivierungsdefizit, der Kraftverlust der verletzten Seite dagegen auf das Aktivierungsdefizit und Muskelatrophie. Aktivierungsdefizite sind vermutlich eine Erklarung dafur, dass sich bei einigen Patienten trotz intensiver Therapie eine Muskelatrophie nicht verhindern lasst. Aufgrund bilateraler Aktivierungsdefizite muss die Validitat von Muskelfunktionstest, die die gesunde Seite als Referenz nutzen, angezweifelt werden.

Bei der Verwendung von Semitendinosussehnen fur die vordere Kreuzbandplastik kommen textile Materialen als Konnektoren fur die Verankerung zum Einsatz. Vor Abschluss der ossaren Integration besitzt die Verankerung hinsichtlich der biomechanischen Stabilitat grose Bedeutung. Die folgende Studie untersuchte die maximale Zuglast sowie die irreversible und elastische Elongation von Nr. 6 Ethibond, 5-mm Mersilene- und 5-mm-Polylenetape in Form von Schlaufen in einer Lange von 30 mm im konditionierten und nichtkonditionierten Zustand unter zyklischen Belastungen bis 50 und 100 N. Fur die Untersuchungen wurde eine axiale Universalprufmaschine verwendet. Die Ergebnisse ergaben nur fur Mersilene eine signifikante Verbesserung der Bruchlast von 416 auf 462 N nach Konditionierung. Polylene besas mit 479 N die signifikant hochste maximale Bruchlast. Bei oszillierenden Belastungen bis 100 N zeigten die unkonditionierten Schlaufen eine Elongation von 4,1 mm fur Ethibond, 2,9 mm fur Polylene und von 5,4 mm fur Mersilene. Nach Konditionierung verringerte sich die Elongation auf maximal 1,4 mm. Auch auf die rein elastische Verlangerung bei Zyklen bis 50 und 100 N bewirkte die Konditionierung eine signifikante Verringerung. Basierend auf diesen Ergebnissen zeigte Polylene die besten mechanischen Eigenschaften. Unabhangig vom Material empfiehlt sich, vor intraoperativer Anwendung die Schlaufen vor zu dehnen, um eine irreversible Verlangerung sowie das elastische Verhalten zu reduzieren.

Summary This study aimed at assessing the possible diagnostic value of cartilage biopsies as a convenient marker for cartilage matrix degradation. We therefore examined cartilage specimens from 56 patients with primary osteoarthritis (OA) of the knee. Resection and biopsy cartilage specimens obtained during joint replacement surgery were used for this study. In addition to histomorphology, immunohistochemistry (ICH) was performed to determine the expression levels and distribution patterns of stromelysin and u-PA protein. The latter data were compared with the degree of histomorphological changes in osteoarthritic cartilage samples, based on a modified version of Mankin's grading score. Compared to the cartilage resection specimens, the biopsies showed comparable expression patterns for both proteinases: the strongest signals were noted in the superficial zone and, as matrix destruction increased, also in the chondrocytes of the transition and deep zones. The strongest signals were ascertained in cell clusters beneath deep matrix fissures. At the immunohistochemical level, we found a direct correlation in the expression ofMMP-3 and u-PA between resection specimens and biopsies. Furthermore, in both types of cartilage samples, we noticed a positive relationship between the expression of both proteins and the Mankin score. Analysis of the expression levels revealed significant differences between deep, transition and superficial zones. Histomorphological and immunohistochemical examinations of MMP-3 and u-PA in biopsies of osteoarthritic cartilage turned out to be useful for estimating the pathological changes within osteoarthritic knee joints. Therefore, in future, cartilage biopsies from osteoarthritic knee joints might serve as a diagnostic tool and thus have an influence on further therapeutic strategies.

Twenty-one patients were evaluated with an average follow up of 30 month after arthroscopical reconstruction of the posterior cruciate ligament using the IKDC-Evaluation Document, Lysholm-Score, KT 1000 and X-ray. Complex ligament injuries and chronic instability of the knee were the indications for operative treatment. Semitendinosus – or patella ligament autografts were used. The Lysholm-Score significantly improved preoperatively to postoperatively (p < 0.01). The IKDC revealed 11 patients for group B, 7 patients for group C and 3 patients for group D. The KT1000 measurement showed a postoperative drawer of 3.6 mm compared with the nonoperated side. Thirteen of the 21 patients showed a posterior drawer of less than 3 mm. The lateral posterior stress view of the X-ray revealed a 4.1 mm ( ± 2.9 mm) side to side difference postoperatively in comparison to 9.5 mm ( ± 3.5 mm) preoperatively. Three patients possessed radiological signs of osteoarthritis grad I by Ahlback. Our results recommend in patients with complex PCL-injuries as well as in cases of chronic posterior instability a complex reconstruction of the ligaments.

Sutures are frequently used in anchoring hamstring or quadriceps tendon grafts in cruciate ligament reconstruction. Trumpet like widening of the femoral bone canal was found in patients having had anterior cruciate ligament reconstruction with hamstring autograft. We investigated 5-mm Polylene tape (Genzyme, Boston, MA) and Mersilene tape (Ethicon, Somerville, NJ) as well as No. 6 Ethibond sutures (Ethicon) for ultimate load, stiffness, and elongation under tension of 50 N, 150 N, 250 N, and ultimate load. The Mersilene and Polylene tapes were tested in single loops and Ethibond in double loops having a length of 30 mm. The length is similar to that used intraoperatively for the graft fixation. The suture materials were loaded using a material testing machine at a strain rate of 60 mm/min. The ultimate loads of the loops with knots were 474 N +/-24.7 N for Polylene, 437 N +/-38.2 N for Mersilene, and 338 N +/-16.8 N for Ethibond, and was statistically significant (analysis of variance [ANOVA], P.05). The elongation under a tension load of 50 N was similar for Ethibond (1.2+/-0.216 mm) and Polylene (1.3+/-0.32 mm). Mersilene (1.7+/-0.34 mm) showed an increased elongation (ANOVA, P=.03). The stiffness for Ethibond was 37.1+/-2.7 N/mm, for Mersilene 38.4+/-3.8 N/mm, and for Polylene was 47+/-3.1 N/mm. The Polylene tape appears to be the most suitable material in terms of strength and stiffness. Nevertheless, the stiffness of all the tested materials is greatly inferior to the stiffness of the commonly used grafts. We believe that a stiffer graft construct might reduce motion during the early period of ingrowing.

This study evaluated the incidence, amount, morphology and clinical significance of bone tunnel widening (TW) at a mean 5-year period after anterior cruciate ligament reconstruction (ACLR) with a transtibial drilling technique. Fifty-nine patients undergoing primary ACLR using quadrupled hamstring autografts, biodegradable transfemoral pins for femoral-sided and 2-mm oversized interference screws for tibial-sided graft fixation were followed up at a mean 61 months postoperatively. Patients were examined clinically and by MRI. Tunnel cross-sectional areas (CSA) were related to drill diameters, which were significantly correlated with radiographic tunnel sizes. Tunnel morphologies were assessed and their positions determined using an anatomical coordinate system. CSA had more than doubled in all segments measured (p

The purpose of the current study was to obtain additional information about the biomechanical behavior of different fixation techniques for meniscus repair using recently developed biodegradable implants and suture repair techniques. The posterior horns of human menisci were used to investigate the meniscus repair construct of the Arrow, Screw, Stinger, Fastener, T-fix, and horizontal and vertical mattress suture. A 20 mm-longitudinal incision was made in the meniscus, similar to a bucket handle lesion, 3 mm from the meniscosynovial rim and was repaired. One hundred cycles between 5 N and 15 N were done using a tension load machine with a loading rate of 10 N/second. The stiffness, displacement, and pullout strength were examined. The significantly highest stiffness was found for the vertical mattress suture (17.1 N/mm) and Stinger (15 N/mm) followed by the Arrow (13.7 N/mm), T-fix (10.5 N/mm), and horizontal mattress suture (10 N/mm). Superior load to failure was obtained for the suture repair in comparison with the biodegradable implants. Despite the lower pullout strength of biodegradable implants, similar stiffnesses were found for the Stinger and Arrow in comparison with the mattress suture technique. These techniques provide the most rigid fixation that is essential for tissue healing.

The purpose of the study was the histological examination of tendon-bone healing of hamstring grafts after anterior cruciate ligament (ACL) reconstruction. During five arthroscopies done 6–14 months after ACL reconstructions, biopsies of the wall of the former drilled femoral canal were obtained. Four patients were primarily operated on using a suspending device (Endobutton, Acufex Microsurgical, Mansfield, MA, USA, and Transfix, Arthrex, Naples, FL, USA) for femoral fixation, one patient was reconstructed with a biodegradable interference screw directly inserted between the tendon and the wall of the canal. Biopsies were obtained using a tube harvester during re-arthroscopy. Three grafts were stable, two grafts were unstable, and revision of the ACL was performed. Histologically, in the four cases of reconstruction with a button or a rectangular pin, biopsies resembled granulation tissue without insertion of fibers between the tendon tissue and the bony wall. A wide area of woven bone was noted adjacent to the pre-existing lamellar bone. In contrast, the tendon-bone junction in the knee reconstructed with a biodegradable interference screw resembled a zone of metaplastic fibrous cartilage between the tendon graft and the lamellar bone. Collagen fibers connecting the tendon-bone interface occurred under polarized light microscopy. We conclude that the use of hamstring grafts for ACL reconstruction can lead to different histological pattern of tendon-bone healing. Micromotion of the hamstring graft inside the drilled canal can be play a role in tendon-bone healing.

We describe a new arthroscopic technique to reinforce the torn inferior glenohumeral ligament (IGHL) and the elongated capsule to the glenoid rim. The arthroscope is inserted over the superior portal and, after the insertion of a suture anchor, both limbs are pulled out over the posterior portal. The IGHL is grasped and pulled upward onto the glenoid rim using a suture retriever clamp inserted over the posterior portal. A 45° curved blunt clamp (Sidewinder; Arthrex, Naples, FL) coming from the anterior penetrates the IGHL, and 1 end of the suture limb is given into the branches of the clamp and pulled out anteriorly. After a second perforation of the capsule, a horizontal suture creating a neolabrum can be placed. This technique allows a suitable reinforcement of the capsule without intraoperative complications. In cases of capsular elongation, especially a torn IGHL, the capsular instability can be addressed by the described Sidewinder technique. More sophisticated arthroscopic techniques such as this will increase the indication for arthroscopic shoulder stabilization. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 4 (April), 2001: pp 426–429

Purpose: Arthroscopic evaluation of the articular surface by visualization and palpation has proved to be unreliable; therefore, we investigated arthroscopically procured biopsy specimens and conventional sections by using the same histopathomorphologic techniques and compared the results for possible differences. Methods: Cartilage biopsy specimens of 1.7 mm in diameter and conventional cartilage sections (pieces of 8 × 2 mm) were removed from the lateral femoral condyle of 53 osteoarthritis patients undergoing total knee arthroplasty. Biopsies and conventional sections were evaluated histologically by using Mankin's grading system and immunohistochemically by assessing the immunoreactivity of the chondrocytes to MMP-1 and MMP-3. Results: The comparison between the biopsies and conventional sections revealed that there were no differences between these forms of obtaining specimens. Moreover, the expression of MMP-1 and MMP-3 in biopsy specimens showed a strong correlation with that in conventional sections. Conclusions: We conclude that in small biopsy specimens taken (e.g., during arthoscopy), the histological grading of osteoarthritis severity and the evaluation of MMP expression yield results similar to those obtained in conventional sections. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 286–289

Two femoral fixation techniques for quadruple hamstring tendon grafts were compared under cyclic loading with the patellar tendon: the rectangular inserted pin (TransFix) and biodegradable interference screw fixation of the quadruple tendon and titanium interference screw fixation of the middle third of the patellar tendon. Porcine specimens were mounted onto a tension load machine, and the tendon-fixation-femur-complex was tested for stiffness, displacement during 800 cycles of loading between 50 and 250 N and ultimate tension load. TransFix fixation showed the greatest stiffness at 183.6 N/mm ( P0.05). The least displacement under cyclic loading was observed for the titanium interference screw followed by the TransFix and biodegradable interference screw ( P0.01). The ultimate tension load was greatest for the TransFix fixation at 1303+/-282 N, followed by patellar tendon fixation with 763+/-103 N and the biodegradable interference screw fixation with 480+/-133 N ( P0.001). To reduce initial elongation of the graft and displacement at the fixation site, preconditioning of both the tendon and tendon-fixation complex is especially important when using quadruple tendons. TransFix fixation provides better stability and greater stiffness and pull-out strength than the other techniques. This finding is of clinical relevance to surgeons of the anterior cruciate ligament.

We performed two rotationplasties (type A1 and A2) as salvage procedures in cases of custom- made endoprosthetic replacements of the distal femur and knee joint. The patients suffered from malignant bone and soft-tissue tumors of the knee, respectively. One of them developed chronic osteomyelitis around both stems of the prosthesis, and three local revisions turned out to be ineffective. The other patient, suffering from parossal osteosarcoma of the distal femur, developed a local recurrence following endoprosthetic reconstruction. The functional abilities following the operation of these two patients suggested that rotationplasty was a viable alternative to above-the-knee amputation in failed or severely complicated total arthroplasty of the knee with massive bone loss.