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Background: While posterior medial meniscus root (PMMR) techniques have evolved, there remains a need to both optimize repair strength and improve resistance to cyclic loading. Hypothesis: Adjustable tensioning would lead to higher initial repair strength and reduce displacement with cyclic loading compared with previously described transtibial pull-out repair (TPOR) fixation techniques. Study Design: Controlled laboratory study. Methods: A total of 56 porcine medial menisci were used. Eight intact specimens served as a control for the native meniscus. For the others, PMMR tears were created and repaired with 6 different TPOR techniques (8 in each group). Fixed PMMR repairs were executed using 4 different suture techniques (two No. 2 cinch sutures, two cinch tapes, two No. 2 simple sutures, and two No. 2 sutures in a Mason-Allen configuration) all tied over a cortical button. Adjustable PMMR repairs using Mason-Allen sutures were fixed with an adjustable soft tissue anchor fixation tensioned at either 80 N or 120 N. The initial force, stiffness, and relief displacement of the repairs were measured after fixation. Repair constructs were then cyclically loaded, with cyclic displacement and stiffness measured after 1000 cycles. Finally, the specimens were pulled to failure. Results: The PMMR repaired with the 2 cinch sutures fixed technique afforded the lowest (P < .001) initial repair load, stiffness, and relief displacement. The adjustable PMMR repairs achieved a higher initial repair load (P < .001) and relief displacement (P < .001) than all fixed repairs. The 2 cinch sutures fixed technique showed an overall higher cyclic displacement (P < .028) and was completely loose compared with the native meniscus functional zone. Repairs with adjustable intratunnel fixation showed displacement with cyclic loading similar to the native meniscus. With cyclic loading, the Mason-Allen adjustable repair with 120 N of tension showed less displacement (P < .016) than all fixed repairs and a stiffness comparable to the fixed Mason-Allen repair. The fixed Mason-Allen technique demonstrated a higher ultimate load (P < .007) than the adjustable Mason-Allen techniques. All repairs were less stiff, with lower ultimate failure loads, than the native meniscus root attachment (P < .0001). Conclusion: Adjustable TPOR led to considerably higher initial repair load and relief displacement than other conventional fixed repairs and restricted cyclic displacement to match the native meniscus function. However, the ultimate failure load of the adjustable devices was lower than that of a Mason-Allen construct tied over a cortical button. All repair techniques had a significantly lower load to failure than the native meniscus root. Clinical Relevance: Knotless adjustable PMMR repair based on soft anchor fixation results in higher tissue compression and less displacement, but the overall clinical significance on healing rates remains unclear.
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Osteoarthritis of the knee, a widespread cause of knee disability, is commonly treated in orthopedics due to its rising prevalence. Lower extremity misalignment, pivotal in knee injury etiology and management, necessitates comprehensive mechanical alignment evaluation via frequently-requested weight-bearing long leg radiographs (LLR). Despite LLR's routine use, current analysis techniques are error-prone and time-consuming. To address this, we conducted a multicentric study to develop and validate a deep learning (DL) model for fully automated leg alignment assessment on anterior-posterior LLR, targeting enhanced reliability and efficiency. The DL model, developed using 594 patients' LLR and a 60%/10%/30% data split for training, validation, and testing, executed alignment analyses via a multi-step process, employing a detection network and nine specialized networks. It was designed to assess all vital anatomical and mechanical parameters for standard clinical leg deformity analysis and preoperative planning. Accuracy, reliability, and assessment duration were compared with three specialized orthopedic surgeons across two distinct institutional datasets (136 and 143 radiographs). The algorithm exhibited equivalent performance to the surgeons in terms of alignment accuracy (DL: 0.21 ± 0.18°to 1.06 ± 1.3°vs. OS: 0.21 ± 0.16°to 1.72 ± 1.96°), interrater reliability (ICC DL: 0.90 ± 0.05 to 1.0 ± 0.0 vs. ICC OS: 0.90 ± 0.03 to 1.0 ± 0.0), and clinically acceptable accuracy (DL: 53.9%-100% vs OS 30.8%-100%). Further, automated analysis significantly reduced analysis time compared to manual annotation (DL: 22 ± 0.6 s vs. OS; 101.7 ± 7 s, p ≤ 0.01). By demonstrating that our algorithm not only matches the precision of expert surgeons but also significantly outpaces them in both speed and consistency of measurements, our research underscores a pivotal advancement in harnessing AI to enhance clinical efficiency and decision-making in orthopaedics.
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Aprendizado Profundo , Humanos , Reprodutibilidade dos Testes , Extremidade Inferior/diagnóstico por imagem , Extremidade Inferior/cirurgia , Articulação do Joelho , Radiografia , Estudos RetrospectivosRESUMO
PURPOSE: The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision. METHODS: Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document. RESULTS: The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article. CONCLUSION: ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults. LEVEL OF EVIDENCE: Level II.
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Lesões do Ligamento Cruzado Anterior , Reconstrução do Ligamento Cruzado Anterior , Humanos , Adulto , Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Lesões do Ligamento Cruzado Anterior/diagnóstico , Lesões do Ligamento Cruzado Anterior/cirurgia , Reoperação , ConsensoRESUMO
INTRODUCTION: The rationale for the use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions is still under debate. The evidence supporting best practise guidelines is based on studies with low-level evidence. A consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence. The purpose of this article is to report the resulting consensus statements. METHODS: Twenty-five experts participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted via an online survey of two rounds, for initial agreement and comments on the proposed statements. An in-person meeting between the panellists was organised during the 2022 ESSKA congress to further discuss and debate each of the statements. A final agreement was made via a final online survey a few days later. The strength of consensus was characterised as: consensus, 51-74% agreement; strong consensus, 75-99% agreement; unanimous, 100% agreement. RESULTS: Statements were developed in the fields of patient assessment and indications, surgical considerations and postoperative care. Between the 25 statements that were discussed by this working group, 18 achieved unanimous, whilst 7 strong consensus. CONCLUSION: The consensus statements, derived from experts in the field, represent guidelines to assist clinicians in decision-making for the appropriate use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions. LEVEL OF EVIDENCE: Level V.
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Traumatismos do Tornozelo , Cartilagem Articular , Humanos , Traumatismos do Tornozelo/cirurgia , Cartilagem Articular/cirurgia , Extremidade Inferior/cirurgia , Artroplastia/métodos , Fêmur/cirurgiaRESUMO
PURPOSE: The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev). METHODS: The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1-3 was considered 'inappropriate', 4-6 'uncertain', and 7-9 'appropriate'). RESULTS: The criteria used to define the scenarios were: age (18-35 years vs 36-50 years vs 51-60 years), sports activity and expectation (Tegner 0-3 vs 4-6 vs 7-10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 0-I-II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51-60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III). CONCLUSION: This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications. LEVEL OF EVIDENCE: II.
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Lesões do Ligamento Cruzado Anterior , Menisco , Osteoartrite do Joelho , Humanos , Adulto , Ligamento Cruzado Anterior/cirurgia , Consenso , Osteoartrite do Joelho/cirurgia , Tratamento Conservador , Lesões do Ligamento Cruzado Anterior/cirurgiaRESUMO
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 < 0.001). The healing status of the PLMR showed no significant association with meniscal extrusion or PROMs (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.
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Lesões do Ligamento Cruzado Anterior , Lesões do Menisco Tibial , Humanos , Masculino , Feminino , Meniscos Tibiais/cirurgia , Estudos Retrospectivos , Seguimentos , Lesões do Menisco Tibial/cirurgia , Artroscopia , Lesões do Ligamento Cruzado Anterior/cirurgia , Imageamento por Ressonância MagnéticaRESUMO
BACKGROUND: Recent evidence questions the role of medial opening wedge high tibial osteotomy (mowHTO) in the correction of femoral-based varus malalignment because of the potential creation of an oblique knee joint line. However, the clinical effectiveness of alternatively performing an isolated lateral closing wedge distal femoral osteotomy (lcwDFO), in which the mechanical unloading effect in knee flexion may be limited, is yet to be confirmed. PURPOSE/HYPOTHESIS: The purpose of this article was to compare clinical outcomes between patients undergoing varus correction via isolated lcwDFO or mowHTO, performed according to the location of the deformity, in a cohort matched for confounding variables. It was hypothesized that results from undergoing isolated lcwDFO for symptomatic varus malalignment would not significantly differ from the results after mowHTO. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Consecutive patients who underwent isolated mowHTO or lcwDFO according to a tibial- or femoral-based symptomatic varus deformity between January 2010 and October 2019 were enrolled. Confounding factors, including age at surgery, sex, body mass index, preoperative femorotibial axis, and postoperative follow-up, were matched using propensity score matching. The International Knee Documentation Committee (IKDC) Subjective Knee Form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively. RESULTS: Of 535 knees assessed for eligibility, 50 knees (n = 50 patients, n = 25 per group) were selected by propensity score matching. Compared with preoperatively, both the mowHTO group (IKDC, 55.1 ± 16.5 vs 71.3 ± 14.7, P = .002; WOMAC, 22.0 ± 18.0 vs 9.6 ± 10.8, P < .001; Lysholm, 55.2 ± 23.1 vs 80.7 ± 16, P < .001; VAS, 4.1 ± 2.4 vs 1.6 ± 1.8, P < .001) and the lcwDFO group (IKDC, 49.4 ± 14.6 vs 66 ± 20.1, P = .003; WOMAC, 25.2 ± 17.0 vs 12.9 ± 17.6, P = .003; Lysholm, 46.5 ± 15.6 vs 65.4 ± 28.7, P = .011; VAS, 4.5 ± 2.2 vs 2.6 ± 2.5, P = .001) had significantly improved at follow-up (80 ± 20 vs 81 ± 43 months). There were no significant differences between the groups at baseline, at final follow-up, or in the amount of clinical improvement in any of the outcome parameters (P > .05; respectively). CONCLUSION: Performing both mowHTO or lcwDFO yields significant improvement in clinical outcomes if performed at the location of the deformity of varus malalignment. These findings confirm the clinical effectiveness of performing an isolated lcwDFO in femoral-based varus malalignment, which is comparable with that of mowHTO in the correction of varus malalignment.
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Osteoartrite do Joelho , Humanos , Osteoartrite do Joelho/cirurgia , Estudos de Coortes , Pontuação de Propensão , Articulação do Joelho/cirurgia , Tíbia/cirurgia , Resultado do Tratamento , Osteotomia/métodos , Estudos RetrospectivosRESUMO
PURPOSE: The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision. METHODS: The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document. RESULTS: The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below. CONCLUSION: ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance. LEVEL OF EVIDENCE: II.
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BACKGROUND: Patellofemoral instability is one of the most common pathologies of the knee joint. The planning and implementation of patella-stabilizing operations are very variable. With regard to the operative measures, the preoperative planning is of decisive importance, especially with regard to the complexity of underlying pathologies. OBJECTIVES: The aim of this study was to depict the current healthcare reality in relation to planning and implementation of patella stabilizing operations in Germany. Furthermore, it was to be ascertained whether automated analysis options would facilitate the planning and implementation of surgical procedures (in primary and revision cases). MATERIALS AND METHODS: An online survey with 16 questions was collected by email among all active members of the German Society of Orthopedic and Trauma Surgery. 7974 members were surveyed; 393 responses could then be analyzed. RESULTS: MPFL-reconstruction (89.8%) is the most frequently performed procedure, followed by tibial tubercle transfers (64.9%), osteotomies (51.2%), and trochleoplasty (19.9%). The choice of surgical approach is mainly based on a combination of clinical and radiological findings (90.3%). MRI imaging (81.2%), standard Xray images (77.4%), and full leg images (76.6%) are mainly used for operative treatment decisions. 59.3% of the respondents would appreciate better preoperative planning and 59.0% would implement more radiologically detectable parameters in their individual preoperative planning if these were automatically available. CONCLUSIONS: The findings of this survey among members of the DGOU identify the MPFL-reconstruction as the central operative approach in the treatment of patellofemoral instabilities, whereas MRI imaging is the diagnostic tool of choice. Future establishment of automated software-based analysis methods could allow a large number of surgeons to expand the radiological parameters taken into account when planning patella-stabilizing operations.
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Luxação Patelar , Articulação Patelofemoral , Humanos , Articulação do Joelho/patologia , Ligamentos Articulares/patologia , Patela/diagnóstico por imagem , Luxação Patelar/diagnóstico , Articulação Patelofemoral/patologiaRESUMO
Purpose: To specifically evaluate the influence of the acromioclavicular (AC)-joint morphology on the outcome after arthroscopically assisted coracoclavicular (CC) stabilization surgery with suspensory fixation systems and to investigate whether an additional open AC-joint reduction and AC cerclage improves the clinical outcome for patients with certain morphologic AC-joint subtypes. Methods: Patients with an acute acromioclavicular joint injury, who underwent arthroscopically assisted CC stabilization with suspensory fixation systems with or without concomitant AC cerclage between January 2009 and June 2017 were identified and included in this retrospective cohort analysis. AC-joint morphology was assessed on preoperative radiographs and categorized as "flat" or "non-flat" ("oblique"/"curved") subtypes. After a minimum of 2 years of follow-up, postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and visual analog scale (VAS) scores for pain were collected. A subgroup analysis of clinical outcomes depending on the surgical technique and morphological subtype of the AC joint was performed. Results: Eighty-one patients (95% male, mean age 35 ± 12 years) could be included at a mean follow-up of 57 ± 14 months. Radiographic assessment of AC-joint morphology showed 24 (30%) cases of flat type, 38 (47%) cases of curved type, and 19 (23%) cases of oblique morphology. Postoperatively, no clinically significant difference could be detected after the treatment of AC joint injury via CC stabilization with or without concomitant AC cerclage (VASrest: P = .067; VASmax: P = .144, ASES: P = .548; SANE: P = .045). No clinically significant differences were found between the surgical techniques for the flat morphologic subtype (VASrest: P = .820; VASmax: P = .251; SANE: P = .104; ASES: P = .343) or the non-flat subtype (VASres: P = .021; VASmax: P = .488; SANE: P = .243, ASES: P = .843). Conclusions: In arthroscopically assisted AC stabilization surgery with suspensory fixation systems for acute AC-joint injury, the AC-joint morphology did not influence the postoperative outcome, independent of the surgical technique. No clinical benefit of performing an additional horizontal stabilization could be detected in our collective at mid-term follow-up. Level of Evidence: Level IV, therapeutic case series.
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PURPOSE: To evaluate immediate loss of reduction in patients undergoing hardware removal after arthroscopically assisted acromioclavicular (AC) joint stabilization using a high-tensile suture tape suspensory fixation system and to identify risk factors associated with immediate loss of reduction. MATERIALS AND METHODS: Twenty-two consecutive patients with a mean age of 36.4 ± 12.6 years (19-56), who underwent hardware removal 18.2 ± 15.0 months following arthroscopically assisted stabilization surgery using a suspensory fixation system for AC joint injury between 01/2012 and 01/2021 were enrolled in this retrospective monocentric study. The coracoclavicular distance (CCD) as well as the clavicular dislocation/acromial thickness (D/A) ratio were measured on anterior-posterior radiographs prior to hardware removal and immediately postoperatively by two independent raters. Loss of reduction, defined as 10% increase in the CCD, was deemed substantial if the CCD increased 6 mm compared to preoperatively. Constitutional and surgical characteristics were assessed in a subgroup analysis to detect risk factors associated with loss of reduction. RESULTS: Postoperatively, the CCD significantly increased from 12.6 ± 3.7 mm (4.8-19.0) to 14.5 ± 3.3 mm (8.7-20.6 mm) (p < 0.001) while the D/A ratio increased from 0.4 ± 0.3 (- 0.4-0.9) to 0.6 ± 0.3 (1.1-0.1) (p = 0.034) compared to preoperatively. In 10 cases (45%), loss of reduction was identified, while a substantial loss of reduction (> 6 mm) was only observed in one patient (4.5%). A shorter time interval between index stabilization surgery and hardware removal significantly corresponded to immediate loss of reduction (11.0 ± 5.6 vs. 30.0 ± 20.8 months; p = 0.007), as hardware removal within one year following index stabilization was significantly associated with immediate loss of reduction (p = 0.027; relative risk 3.4; odds ratio 11.67). CONCLUSIONS: Substantial loss of reduction after hardware removal of a high-tensile suture tape suspensory fixation system was rare, indicating that the postoperative result of AC stabilization is not categorically at risk when performing this procedure. Even though radiological assessment of the patients showed a statistically significant immediate superior clavicular displacement after this rarely required procedure, with an increased incidence in the first year following stabilization, this may not negatively influence the results of ACJ stabilization in a clinically relevant way. LEVEL OF EVIDENCE: IV.
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Articulação Acromioclavicular , Luxações Articulares , Articulação Acromioclavicular/lesões , Articulação Acromioclavicular/cirurgia , Adulto , Artroscopia/métodos , Clavícula/lesões , Clavícula/cirurgia , Humanos , Luxações Articulares/cirurgia , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To evaluate return to sport (RTS) and work (RTW), as well as clinical outcomes following double level osteotomy (DLO) via combined medial open wedge high tibial osteotomy and lateral closing wedge distal femoral osteotomy for bifocal symptomatic varus malalignment, and to compare these outcome parameters between patients undergoing a single surgery and those undergoing a two-stage procedure. METHODS: Consecutive patients who underwent DLO for symptomatic varus malalignment between 12/2007 and 03/2018 were enrolled. Patients converted to arthroplasty (n = 3) during follow-up were excluded. Outcome measures included the International Knee Documentation Committee (IKDC) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain, which were collected preoperatively and at a minimum of 24 months postoperatively. RTS and RTW were evaluated by questionnaire. Outcome measures were compared between DLO performed in a single- versus a two-stage surgery. RESULTS: Thirty-two patients (mean age: 44.2 ± 12.6 years), who underwent DLO for varus malalignment (10.1° ± 2.9°) were included at a mean follow-up of 56.9 ± 35.3 months (range: 24-148). Compared to preoperatively, these patients significantly improved in IKDC (50.4 ± 13.9 to 66.1 ± 15.4; P < .001), WOMAC (29.7 ± 19.2 to 11.8 ± 13.5; P < .001) and Lysholm (53.6 ± 23.6 to 73.1 ± 23.6; P = .002) scores at final follow-up. For the WOMAC score, 78% of the patients included reached the minimally important clinical difference, along with a significant reduction of the VAS for pain (5.0 ± 3.0 to 2.5 ± 2.4; P < .001). Postoperatively, 96% of patients returned to sport after 7.7 ± 4.8 months, but at a lower frequency (P = .010) and to fewer disciplines (P = .005) with a shift to low-impact sports. 90% of the patients returned to work at a mean 5.9 ± 9.4 months, with 79% reporting a similar or superior working ability. Patients undergoing a two-stage procedure recovered to full physical working ability at a significantly longer duration, as compared to a single-stage procedure (9.8 ± 3.8 vs 9.0 ± 13.1 months; P = .047). CONCLUSION: The majority of patients undergoing DLO for symptomatic varus malalignment, who were not converted to arthroplasty, experienced clinically significant functional improvement at mid-term follow-up. Return to sport and work rates in these patients were high; however, a shift to lower-impact sports disciplines was observed. Similar clinical outcomes can be expected when performing DLO in a single surgery or a two-stage procedure. LEVEL OF EVIDENCE: Retrospective case series; Level IV.
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Osteoartrite do Joelho , Adulto , Humanos , Articulação do Joelho/cirurgia , Pessoa de Meia-Idade , Osteoartrite do Joelho/etiologia , Osteotomia/métodos , Dor/etiologia , Estudos Retrospectivos , Volta ao Esporte , Tíbia/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: High tibial osteotomy (HTO) is a valid and joint preserving surgical technique to treat medial degenerative osteoarthritis (OA) in young and active patients. A recent study shows that patients' expectations of osteotomy around the knee are high, but OA progression and potential conversion to a total knee arthroplasty (TKA) were underestimated. The aim of this study was to investigate surgeons' expectations of HTO and to compare the results to the patients' expectations and actual outcomes reported in the literature. METHODS: 461 surgeons were questioned online using the 'Hospital for Special Surgery Knee Surgery Expectations Survey (HFSS-KSES)' and a ten-item non-validated questionnaire to investigate the expectations of HTO. Two subgroups were formed to investigate differences regarding the surgeons' experience. Statistical analysis was performed using IBM SPSS Statistics. RESULTS: Surgeons' expectations of HTO were rated between very and little important with pain reduction being the most important item on the HFSS-KSES. Furthermore, 'improving the ability to walk', 'to perform daily activities', 'having confidence in the knee', and 'avoiding future degeneration' were rated of high importance. An important difference regarding the experience was the lower expectations on delay/prevention of TKA of less-experienced surgeons. CONCLUSION: Surgeons' expectations of HTO are high but nevertheless different to the patients' expectations reported in the literature. Also, expectations for the delay/prevention of TKA differed regarding the experience of surgeons. While pain reduction represents one of the most important items for surgeons and patients, the expected outcome regarding the delay/prevention of a TKA and returning to sports differs to the patients' expectations and to the actual outcome reported in the literature. This should be considered when performing the preoperative informed consent.
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Osteoartrite do Joelho , Cirurgiões , Humanos , Articulação do Joelho/cirurgia , Motivação , Osteoartrite do Joelho/cirurgia , Osteotomia/métodos , Dor , Tíbia/cirurgia , Resultado do TratamentoRESUMO
PURPOSE: Trochlear dysplasia is a significant risk factor for patellofemoral instability. The severity of trochlear dysplasia is commonly evaluated based on the Dejour classification in axial MRI slices. However, this often leads to heterogeneous assessments. A software to generate MRI-based 3D models of the knee was developed to ensure more standardized visualization of knee structures. The purpose of this study was to assess the intra- and interobserver agreements of 2D axial MRI slices and an MRI-based 3D software generated model in classification of trochlear dysplasia as described by Dejour. METHODS: Four investigators independently assessed 38 axial MRI scans for trochlear dysplasia. Analysis was made according to Dejour's 4 grade classification as well as differentiating between 2 grades: low-grade (types A + B) and high-grade trochlear dysplasia (types C + D). Assessments were repeated following a one-week interval. The inter- and intraobserver agreement was determined using Cohen's kappa (κ) and Fleiss kappa statistic (κ). In addition, the proportion of observed agreement (po) was calculated for assessment of intraobserver agreement. RESULTS: The assessment of the intraobserver reliability with regard to the Dejour-classification showed moderate agreement values both in the 2D (κ = 0.59 ± 0.08 SD) and in the 3D analysis (κ = 0.57 ± 0.08 SD). Considering the 2-grade classification, the 2D (κ = 0.62 ± 0.12 SD) and 3D analysis (κ = 0.61 ± 0.19 SD) each showed good intraobserver matches. The analysis of the interobserver reliability also showed moderate agreement values with differences in the subgroups (2D vs. 3D). The 2D evaluation showed correspondences of κ = 0.48 (Dejour) and κ = 0.46 (high / low). In the assessment based on the 3D models, correspondence values of κ = 0.53 (Dejour) and κ = 0.59 (high / low) were documented. CONCLUSION: Overall, moderate-to-good agreement values were found in all groups. The analysis of the intraobserver reliability showed no relevant differences between 2 and 3D representation, but better agreement values were found in the 2-degree classification. In the analysis of interobserver reliability, better agreement values were found in the 3D compared to the 2D representation. The clinical relevance of this study lies in the superiority of the 3D representation in the assessment of trochlear dysplasia, which is relevant for future analytical procedures as well as surgical planning. LEVEL OF EVIDENCE: Level II.
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Instabilidade Articular , Humanos , Instabilidade Articular/cirurgia , Articulação do Joelho , Imageamento por Ressonância Magnética , Reprodutibilidade dos Testes , SoftwareRESUMO
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 < 0.05). 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.
Assuntos
Fraturas Ósseas , Osteoartrite do Joelho , Adulto , Fêmur/cirurgia , Fraturas Ósseas/etiologia , Humanos , Pessoa de Meia-Idade , Osteoartrite do Joelho/cirurgia , Osteotomia , Radiografia , Tíbia/cirurgiaRESUMO
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.
Assuntos
Osteoartrite do Joelho , Osteoartrite , Articulação Patelofemoral , Artroplastia/métodos , Seguimentos , Humanos , Osteoartrite/cirurgia , Osteoartrite do Joelho/cirurgia , Dor/cirurgia , Patela/cirurgia , Articulação Patelofemoral/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
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.
Assuntos
Instabilidade Articular , Fraturas da Tíbia , Humanos , Masculino , Feminino , Criança , Adolescente , Adulto Jovem , Adulto , Volta ao Esporte , Estudos Retrospectivos , Artroscopia/métodos , Fraturas da Tíbia/cirurgia , Fraturas da Tíbia/complicações , Fixação Interna de Fraturas/métodos , Técnicas de Sutura , Instabilidade Articular/cirurgia , Instabilidade Articular/complicações , Resultado do TratamentoRESUMO
PURPOSE: Anterior cruciate ligament (ACL) injuries are often combined with lesions of the medial collateral ligament (MCL). The aim of this study was to evaluate treatment outcome of combined acute ACL and MCL lesions using functional US and clinical examination. METHODS: Patients aged > 18 years undergoing primary ACL reconstruction with concomitant operative (group 1) or non-operative treatment of the MCL (group 2) between 2014 and 2019 were included after a minimum follow-up of 12 months. Grade II MCL injuries with dislocated tibial or femoral avulsions and grade III MCL ruptures underwent ligament repair whereas grade II injuries without dislocated avulsions were treated non-operatively. Radiological outcome was assessed with functional US examinations. Medial knee joint width was determined in a supine position at 0° and 30° of knee flexion in unloaded and standardized loaded (= 15 Dekanewton) conditions using a fixation device. Clinical examination was performed and patient-reported outcomes were assessed by the use of the subjective knee form (IKDC), Lysholm score, and the Tegner activity scale. RESULTS: A total of 40 patients (20 per group) met inclusion criteria. Mean age of group 1 was 40 ± 12 years (60% female) with a mean follow-up of 33 ± 17 months. Group 2 showed a mean age of 33 ± 8 years (20% female) with a mean follow-up of 34 ± 15 months. Side-to-side differences in US examinations were 0.4 ± 1.5 mm (mm) in 0° and 0.4 ± 1.5 mm in 30° knee flexion in group 1, and 0.9 ± 1.1 mm in 0° and 0.5 ± 1.4 mm in 30° knee flexion in group 2, with no statistically significant differences between both groups. MCL repair resulted in lower Lysholm scores (75 ± 19 versus 86 ± 15; p < 0.05). No significant differences could be found for subjective IKDC or Tegner activity scores among the two groups. CONCLUSION: A differentiated treatment concept in combined ACL and MCL injuries based on injury patterns leads to reliable postoperative ligamentous knee stability in US-based and clinical examinations. However, grade II and III MCL lesions with subsequent operative MCL repair (group 1) result in slightly poorer subjective outcome scores. LEVEL OF EVIDENCE: Retrospective cohort study; Level III.
RESUMO
BACKGROUND: Ischial tuberosity apophyseal fractures are avulsion fractures of the anatomic footprint of the proximal hamstring tendons. Generally, these injuries are rare and frequently occur in skeletally immature, active patients due to incomplete ossification. Depending on the fragment displacement, non-operative or operative treatment approaches are used. CASE PRESENTATION: We report a case of a 29-year-old professional volleyball athlete who has suffered from a nonunion avulsion fracture for 14 years. Isolated suture anchor fixation was performed after open excision of a large bony fragment followed by excellent clinical and functional outcome at 1 year postoperatively. CONCLUSION: In conclusion, avulsion fractures of the ischial tuberosity with large fragments and restrictions to activities of daily living due to pain can, in individualized cases, be treated with an open excision of the fragment followed by repair of the proximal hamstring tendons using suture anchors.
Assuntos
Tendões dos Músculos Isquiotibiais , Voleibol , Atividades Cotidianas , Adulto , Atletas , Humanos , Ísquio/diagnóstico por imagem , Ísquio/cirurgiaRESUMO
BACKGROUND: Commonly used cartilage repair procedures have been established for focal cartilage lesions; however, degenerative lesions with accompanying changes of other intraarticular structures are much more common in clinical practice. This stage, in which classic radiological signs of osteoarthritis are absent, is called early osteoarthritis and is characterized by impaired joint homeostasis with biomechanical and biochemical changes that can have a negative effect on regenerative cartilage therapy procedures. INDICATION: Cartilage repair procedures are indicated for symptomatic focal early osteoarthritis, defined as cartilage degeneration ICRS grades I or II around a focal cartilage defect ICRS grades III or IV. In more advanced osteoarthritis with significant narrowing of the joint space, cartilage repair procedures are generally contraindicated. THERAPY: The most studied cartilage repair procedure for early osteoarthritis is autologous chondrocyte implantation, which has shown acceptable results in case series, although higher failure rates are to be expected compared to focal, traumatic cartilage lesions. The use of bone marrow-stimulating techniques seems to be limited in early osteoarthritis and should only be used in cases of lesion <â¯2â¯cm2 and very little surrounding cartilage degeneration. Concomitant surgical procedures, especially unloading osteotomies, are very important.