Application of bone cement directly to the implant in primary total knee arthroplasty. Short-term radiological and clinical follow-up of two different cementing techniques.

PURPOSE: This study aimed to optimize cement application techniques in fully cemented primary total knee arthroplasty (TKA) by comparing the effects of two different approaches: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term presence of radiolucent lines (RLL) as indicators of potential complications. METHODS: In this monocentric study, a total of 379 fully cemented primary TKAs (318 patients) were included. The two study groups were differentiated by the technique of cement application: CoB group (cement applied only on bone surface) and CoBaI group (cement applied on both bone surface and implant surface). The presence of RLL or osteolysis was evaluated using the updated Knee Society Radiographic Evaluation System. RESULTS: In the whole study population, RLL were present in 4.7% of cases, with a significantly higher incidence in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up, RLL were observed in 29.8% of TKAs in the CoBaI group, while the incidence was lower in the CoB group (24.0%) (not statistically significant). There were two revisions in each group, none of which were due to aseptic loosening. CONCLUSION: The findings of this study suggest that the application of bone cement on bone surface only (CoB) may be more beneficial than applying it on both bone surface and implant surface (CoBaI) in terms of short-term presence of RLL in fully cemented primary TKA. Long-term results, especially with regard to aseptic loosening, will be of interest and may provide valuable guidance for future directions in bone cement applications in TKA.

Patient-specific instrumentation in total knee arthroplasty: a review of the current literature.

Total knee arthroplasty (TKA) is one of the most frequently performed interventions in the field of Orthopaedic surgery. Over the last decades the implantation technique has improved continuously. The majority of patients is satisfied with the clinical outcome of TKA. However in various clinical follow-ups, up to 20% of unsatisfied patients can be observed. Periprosthetic infection and aseptic loosening seem to be the most common reasons for failure. Malalignment has been discussed as a cause of aseptic loosening and often leads to revision surgery. In order to increase the precision of implant positioning and alignment, new technologies such as patient-specific instrumentation (PSI) have been developed. Since the introduction of PSI, multiple clinical studies have been performed analyzing the clinical and radiological outcome of TKA with PSI technique. This review covers the recent literature of PSI in respect to surgical accuracy, clinical outcome, time- and cost-effectiveness.

How to Manage Metallosis: A Retrospective Cohort Analysis after Revision Hip Surgery.

BACKGROUND: Adverse local tissue reactions to metal debris are due to a metal-on-metal bearing complication caused by micromotions at modular interfaces that induce corrosion of the protective oxide layer. This process could lead to wear, fretting, and abrasion with the release of metal ions locally and systemically, which may cause adverse local reactions in nearby tissues. The aim of this study is to describe a series of patients with painful local adverse tissue reactions secondary to corrosion at the modular neck-body interface, to document the clinical presentation, diagnostic workup, and surgical findings of our research, and to search for a possible correlation between metallosis and infection. METHODS: A retrospective study of patients with adverse local tissue reactions due to metal surface corrosion was performed. Blood samples were collected to identify erythrocyte sedimentation rate, C reactive protein, and procalcitonin, and a magnetic resonance imaging protocol was performed. RESULTS: Serum cobalt and chromium levels of the 43 patients tested were significantly higher on average. However, both erythrocyte sedimentation rate and C-reactive protein were significantly elevated. Magnetic resonance imaging showed adverse reactions to metal debris with large soft tissue masses and surrounding tissue damage. CONCLUSIONS: Corrosion in hip prosthesis can lead to the release of metal ions and debris locally and systemically, resulting in local soft tissue changes. A "tumor-like" debridement can reduce this complication.

Predictive Value of the C-Reactive Protein to Albumin Ratio in 30-Day Mortality after Hip Fracture in Elderly Population: A Retrospective Observational Cohort Study.

BACKGROUND: C-reactive protein (CRP) to Albumin ratio (CAR) has been used in multiple clinical settings to predict early mortality. However, there is a lack of evidence on the predictive role of CAR in 30-day mortality after a hip fracture. The purpose of this study was to establish a potential association between CAR and 30-day mortality and to assess if the CAR Receiving Operating Characteristics curve (ROC) can be a reliable predictor of early mortality. METHODS: We retrospectively reviewed the charts of 676 patients (>65 years) treated for hip fracture between 2006 and 2018. All hip fractures were included. Treatment strategies included closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty, or total joint arthroplasty. Statistical analysis included T-test, Pearson correlation for CAR and other markers, ROC curves and area under the curve, Youden Model, and Odds Ratio. RESULTS: The 30-day mortality rate analysis showed that higher preoperative levels of CAR were associated with higher early mortality. When analyzing the area under the ROC curve (AUROC) for 30-day mortality, the reported value was 0.816. The point of the ROC curve corresponding to 14.72 was considered a cut-off with a specificity of 87% and a sensibility of 40.8%. When analyzing values higher than 14.72, the 30-day mortality rate was 17.9%, whilst, for values lower than 14.72, the 30-day mortality rate was 1.8%. CONCLUSIONS: Patients older than 65 years affected by a hip fracture with increased preoperative levels of CAR are associated with higher 30-day mortality. Despite a moderate sensibility, considering the low cost and the predictivity of CAR, it should be considered a standard predictive marker.

Total Hip Arthroplasty: So Hip It Hurts.

Total hip arthroplasty (THA) has become a standard surgical intervention for patients with hip joint disorders [...].

Evaluation of FRAX in patients with periprosthetic fractures following primary total hip and knee arthroplasty.

The fracture risk assessment tool (FRAX) is a tool which calculates an individual 10-year fracture risk based on epidemiological data in patients with a risk of osteporosis. The aim of this study was to evaluate the value of FRAX to estimate the risk of postoperative periprosthetic fractures (PPF) in patients following with total hip and knee arthroplasty. 167 patients (137 periprosthetic fractures in total hip arthroplasty and 30 periprosthetic fractures in total knee arthroplasty) were included in this study. Patients' data was retrieved retrospectively. In each patient the 10-year probability of a major osteoporotic fracture (MOF) and an osteoporotic hip fracture (HF) was calculated using FRAX. According to the NOGG guideline 57% of total hip arthroplasty (THA) patients and 43.3% of total knee arthroplasty (TKA) patients were in need of osteoporosis treatment, whereas only 8% and 7% received an adequate one respectively. 56% of the patients with PPF after THA and 57% of the patients with PPF after TKA reported about a previous fracture. Significant associations between the 10-year probability of a MOF and HF calculated by FRAX and PPF in THA and TKA were seen. The results of the present study show that FRAX might have the potential to estimate the PPF in patients following THA and TKA. FRAX should be calculated before and after THA or TKA in order to assess the risk and counsel patients. The data show a clear undertreatment of patients with PPF in respect to osteoporosis.

Arthroscopic findings and treatment of maisonneuve fracture complex.

BACKGROUND: The Maisonneuve fracture complex (MFC) is a well-known lower leg injury. However, the optimal treatment is still not clear and there is limited data on concomitant injuries of cartilage. Therefore, the aim of our study was to report the incidence of incidental cartilage injuries and their management in arthroscopic treatment of MFC. PATIENTS AND METHODS: Between February 2018 and February 2021 all patients presenting with MFC in our department were treated with diagnostic ankle arthroscopy and percutaneous syndesmotic screw or suture-endobutton fixation. In case of instable cartilage, it was debrided and according to the International Consensus Meeting on Cartilage Repair of the Ankle, in grade IV lesions < 10 mm or < 100 mm2 area the subchondral bone was microfractured. RESULTS: Eighteen patients, 16 male and two female, with a mean age of 48.1 years, were included. In all cases, instability of the distal tibiofibular articulation was confirmed arthroscopically. Injuries of the cartilage were found in 56% of the cases and in 31% of the patients surgical intervention was required. In three talar and one tibial lesion additional arthroscopic bone marrow stimulation with microfracture of the subchondral bone was performed. CONCLUSIONS: Ankle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries. Due to the high rate of chondral lesions, addressing these arthroscopically may contribute to better postoperative results. LEVEL OF EVIDENCE: IV.

Patient-reported outcomes after primary rotating hinge total knee arthroplasty: a multi-centre clinical cohort study.

PURPOSE: Rotating hinge prostheses for total knee arthroplasty (TKA) are mostly used in revision setting; however, evidence on the use of these constrained devices in primary setting is scarce and inconsistent. Therefore, we aimed to evaluate the functional outcomes after third-generation rotating hinge implants in primary TKA with a minimal follow-up of two years in a large dual-centre observational retrospective clinical trial. METHODS: The hospital databases of two centres were searched for primary rotating hinge arthroplasty from January 2007 to January 2015. A minimum follow-up of at least two years was assured. Patients meeting the inclusion criteria were asked to fill out two self-reported functional scores, the Oxford Knee Score (OKS) and Forgotten Joint Score (FJS), to measure the functional status of the knee. RESULTS: In total, 267 primary rotating hinge knee arthroplasties in 242 patients were performed in two centres. The three major indications were axial malalignment (valgus/varus > 15°), 87/267 (33%), persistent ligamentous instability (28%) and neuromuscular disorders (12%). 184 patients with 202 primary rotating hinge knee arthroplasties could be included that provided data of the self-reported outcome measures (OKS and FJS). A mean OKS score of 37.71 (± 9.23) and a mean FJS score of 63.65 (± 31.01) could be obtained. CONCLUSION: This large clinical study suggests that constrained devices provide the best results when treating bone-on-bone tricompartimental osteoarthritis of the knee with severe axial deviation (valgus/varus > 15°) and/or persistent ligamentous instability.

The most influential papers in unicompartmental knee arthroplasty.

PURPOSE: Unicompartmental knee arthroplasty (UKA) is a treatment option for anteromedial osteoarthritis of the knee. The number of UKA has been increasing constantly worldwide in recent decades. The aim of this study was to determine the most frequently cited scientific articles addressing this subject and to establish a ranking of the 50 most influential papers. METHODS: The 50 most cited articles related to UKA were searched in Web of Science® (Clarivate Analytics, Penn., USA) by the use of defined search terms. All types of scientific papers with reference to this topic were ranked according to the absolute number of citations and analyzed for the following characteristics: journal title, year of publication, number of citations, citation density, geographic origin, article type, and level of evidence. RESULTS: The 50 most cited articles had up to 453 citations. Most papers were published in the Journal of Bone and Joint Surgery (British volume). More than half of the articles were published in the 2000s and 2010s (n = 30). Ten countries contributed to the top 50 list, with most contributions from the UK (n = 17). Most articles could be attributed to the category of Clinical Science (n = 33), and most reported level IV studies. CONCLUSION: Most of the frequently cited articles in UKA are clinical studies that have a low level of evidence. Few basic scientific studies could be identified, which suggests that most product development is done by commercial companies.

Bone marrow aspirations in Ewing sarcomas: Are they still necessary? A single-center retrospective analysis and review of the literature.

BACKGROUND AND OBJECTIVES: Currently, one of the most useful prognostic indicators in Ewing sarcomas (ES) is the presence of metastatic disease at diagnosis. According to various clinical guidelines, the assessment of bone marrow (BM) metastases, using light microscopy examination of bone marrow aspirates and biopsies (BMAB) is mandatory. However, the prognostic value of BM positivity is discussed controversially. Therefore, the primary aim of this study was to retrospectively review BM samples from patients with ES. MATERIALS AND METHODS: This retrospective single centre study included 31 patients that were newly diagnosed with ES between 2000 and 2014. Twenty-seven patients had skeletal ES and in 4 patients the tumour was localized in the soft tissue only. Metastases at diagnosis were present in 5 out of 31 patients. BM samples were morphologically and immunohistochemically searched and screened for the presence or absence of BM metastases. Furthermore, in 15 of the 31 patients BM samples were still available and were reanalysed, using nested-polymerase chain reaction. RESULTS: All BM samples of our 31 ES patients, including the 5 metastatic patients, were, morphologically and immunohistochemically tested negative for tumour cell appearance. The nested-PCR results were also negative in all of our 15 retested patients, including two patients with metastatic disease. CONCLUSIONS: Based on our results and on the contradictory results reported in the literature we recommend a re-evaluation of the necessity and the prognostic value of BMAB in the initial staging process of newly diagnosed ES patients.

Adolf Lorenz and the Lolita Armour Case.

Almost 120 years ago, in 1902, the American multimillionaire J. Ogden Armour invited the Austrian orthopaedic surgeon Adolf Lorenz, professor at the University of Vienna, to treat his daughter Lolita. Lolita was born premature in 1896 and spent the first months of her life in an incubator. Later she was diagnosed with congenital dislocation of both hips. Lorenz had developed a "bloodless" treatment method and was invited by the Armour family to Chicago to "operate" on Lolita. Both hips had already been treated by an American orthopaedic surgeon before but without a satisfactory result. Lorenz should achieve a better one. The operation was performed in Chicago on 12 October 1902 and was accompanied by a very large media spectacle. This article is mainly based on contemporary newspaper reports.

Failure after proximal humeral fracture osteosynthesis: a one year analysis of hospital-related healthcare cost.

PURPOSE: The issue of rising healthcare costs and limited resources is a topic of worldwide discussion over the last several decades. We hypothesized that failure of proximal humeral fracture osteosynthesis is presumed to be an important determinant in healthcare resources and related costs. The aim of this study was to calculate the total hospital-related healthcare cost of proximal humeral fracture osteosynthesis over one  year focusing on failure. METHODS: A total of 121 patients with a proximal humeral fracture treated by angular stable osteosynthesis were included in this retrospective study. All hospital-related healthcare costs were investigated. Five main hospital-related cost categories were defined: hospitalization cost, honoraria, day care admission, materials, and pharmaceuticals. RESULTS: A total healthcare cost of € 1,139,448 was calculated for the whole patient group. Twelve patients needed revision surgery due to complications or fixation-related failure. This failure rate alone costed € 190,809 of the healthcare resources. In other words, failure after proximal humeral fracture osteosynthesis costed 17% of the total healthcare expenditure inone year. CONCLUSION: This study demonstrates that a high amount of hospital-related healthcare resources is spent because of failure after proximal humeral fracture osteosynthesis. Further research is necessary and should investigate on how to prevent failure. This is not only in the patient's interest, but it is also of great importance for maintaining a healthy healthcare system.

Body image, self-esteem, and quality of life in patients with primary malignant bone tumors.

BACKGROUND: Patients with primary malignant bone tumors are facing different challenges in their everyday lives due to improved treatment and prolonged survival. This raises the question whether and to what extent their quality of life, body image, and self-esteem is affected by their disease. The aim of this retrospective study was to analyze the quality of life, body image and self-esteem of patients with primary malignant bone tumors compared to a healthy control group. METHODS: A total of 56 patients (39 male, 17 female; average age 33.8 [± 14.29] years) who were treated with either osteosarcoma or Ewing-Sarcoma at the authors' institution between Jan 1989 and May 2015 were included into the study (mean follow-up: 9.1 ± 6.6] years). The control group consisted of 58 (average age 24.4 [± 3.1] years, 31 male, 27 female) healthy medical students. Standardized questionnaires were used to assess quality of life (SF-36), body image (MBSRQ) and self-esteem (RSE-scale). Student's t test were used for statistical analysis. RESULTS: Quality of life (SF-36) (in physical categories) and body image (MBSRQ) was significantly lower in patients with primary malignant bone tumors compared to healthy cohort (p < 0.001). Self-esteem was not affected i n patients and did not show any difference compared to control group (23.96 vs. 24.00). DISCUSSION: Physical categories of quality of life and body image sensation of patients with primary malignant bone tumors are worse compared healthy controls. However, self-esteem does not seem to be affected by the condition and its management. Patients can be encouraged about this at the time of diagnosis of a primary malignant bone tumor.

Differences in intraosseous and extraosseous post-chemotherapy regression of Ewing sarcomas and their influence on prognosis.

BACKGROUND: In Ewing sarcomas (ES), histological response to polychemotherapy is the main prognostic factor. We aimed at evaluating the histological response separately for the extraosseous and intraosseous tumor compartment as well as its prognostic influence. METHODS: Thirty-one patients with ES and marked soft tissue expansion, treated at our department between January 2006 and December 2015, were retrospectively included. Data was taken from medical records. Original histologic specimens of the resected tumors were re-evaluated separately for intra- and extraosseous tumor regression according to Salzer-Kuntschik regression grading. Multivariate survival analysis with stepwise backward variable selection was calculated to determine the impact of extraosseous and intraosseous regression on prognosis. RESULTS: All patients had received chemotherapy, 15 (48.4%) had been administered preoperative radiotherapy. Extraosseous tumor regression was significantly worse than intraosseous regression (Wilcoxon signed-rank test, p = 0.018). While neither intraosseous nor extraosseous tumor regression had an impact on overall survival, extraosseous complete remission had a beneficial impact on event-free-survival in the multivariate analysis (Cox-regression; hazard ratio: 0.148, 95% confidence interval 0.031-0.707, p = 0.017). CONCLUSIONS: On average, regression of ES seems to be worse in the extraosseous tumor compartment following preoperative chemotherapy. Moreover, extraosseous tumor regression may have a stronger prognostic influence on event-free survival than intraosseous regression.

Fetal Rhabdomyoma of the upper Extremity in a 31-Year Old Patient: a Case Report.

Fetal rhabdomyomas (RM) are extremely rare benign mesenchymal tumours that occur primarily in the head and neck. This tumour exhibits immature skeletal muscle differentiation. The patients' median age is four years and surgical resection is the recommended treatment. Fetal RM of limbs are rare and not well described in the literature and if, predominantly in form of case reports. We report the second case of a fetal RM in the upper extremity in a 31-year old male patient. One should be aware of this skeletal muscle tumour and fetal RM should be considered as a differential diagnosis to its malignant counterpart rhabdomyosarcoma.

The accuracy of digital templating in uncemented total hip arthroplasty.

INTRODUCTION: Preoperative planning is an essential part of total hip arthroplasty (THA). It facilitates the surgical procedure, helps to provide the correct implant size and aims at restoring biomechanical conditions. In recent times, surgeons rely more and more on digital templating techniques. Although the conversion to picture archiving and communication system had many positive effects, there are still problems that have to be taken into consideration. OBJECTIVES: The core objective was to evaluate the impact of the planners' experience on the accuracy of predicting component size in digital preoperative templating of THA. In addition, the influence of overweight and obesity (according to WHO-criteria), patient's sex and component design on the accuracy of preoperative planning have been analysed. MATERIALS AND METHODS: The retrospective study included 632 consecutive patients who had primary uncemented THA. Digital templating was done using "syngo-EndoMap" software by Siemens Medical Solutions AG. Mann-Whitney U test and Kruskal-Wallis test have been used for statistical analysis. The accuracy of predicting component size has been evaluated by comparing preoperative planned sizes with implanted sizes as documented by the surgeons. The planner's experience was tested by comparing the reliability of preoperative planning done by senior surgeons or residents. The influence of BMI on predicting component size has been tested by comparing the accuracy of digital templating between different groups of BMI according to WHO-criteria. The same procedure has been done for evaluating the impact of patient´s sex and component design. RESULTS: The implant size was predicted exactly in 42% for the femoral and in 37% for the acetabular component. 87% of the femoral components and 78% of the acetabular cups were accurate within one size. Digital templating of femoral implant size was significantly more reliable when done by a senior surgeon. No difference was found for the acetabular component sizes. The BMI also had an impact on estimating the correct femoral implant size. In overweight patients, planning was significantly more inaccurate than normal weight people. Differences were seen in obese patients. However, these were not significant. Accuracy of acetabular components was not affected. The design of the prostheses and the patient's sex had no influence on predicting component size. CONCLUSIONS: Inexperience and overweight are factors that correlate with inaccuracy of preoperative digital templating in femoral components, whereas acetabular components seem to be independent of these factors.

Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review.

OBJECTIVE: Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system. DESIGN: Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded. RESULTS: 47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data. CONCLUSIONS: We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.

Knee alignment in adolescents is correlated with participation in weight-bearing sports.

PURPOSE: Weight-bearing sports might influence the alignment of the lower extremities during growth. The relationship between participation in weight-bearing sports and the alignment of the lower extremities in adolescents has not been adequately studied yet. The aim of the study was to investigate whether sports participation during growth in early adolescence is correlated with the development of genu varum. METHODS: The design was a correlation study in which 1008 (564 boys, 444 girls) healthy adolescents (from 12 to 19 years of age) were recruited in secondary schools. The alignment of the knee was determined by measuring the intercondylar (IC) and intermalleolar (IM) distance using a specially designed instrument and an inside calliper. The degree of sports participation of the participants was determined by a questionnaire in which they were asked how many hours a week they participated in sports and for how many years in total. RESULTS: The results of this study revealed a significant correlation between participation in weight-bearing sports and genu varum in each of three different age groups, both for boys and girls. CONCLUSION: Our results show that there is an association between the alignment of the knee joint and participation in weight-bearing sports during early adolescence.

Clinical experience with the artificial bone graft substitute Calcibon used following curettage of benign and low-grade malignant bone tumors.

Artificial bone graft substitutes, such as Calcibon, are becoming increasingly interesting as they do not cause donor site morbidity which is an advantage compared to autologous bone grafts. The aim of this study was to evaluate the efficacy and potential complications associated with the use of Calcibon. Twenty-seven patients with benign and low-grade malignant bone tumors were treated with curettage and refilling of the bony cavity. Based on the radiological classification system of Neer, these lesions only comprised Grade I lesions, describing cysts that only require curettage and filling, but no additional treatment. At a mean follow up of six months we observed radiological consolidation without resorption of the bone graft substitute. These observations were also made at a mean follow-up of 13 and 32 months, respectively. According to the classification system of Goslings and Gouma we observed six surgical complications. Summing up, Calcibon seems to be a reliable bone graft substitute with low complication rates. However, delayed resorption should be expected. Calcibon seems to be an alternative to autologous bone grafts or allografts in adequate indications.

The fifty highest cited papers in anterior cruciate ligament injury.

INTRODUCTION: The anterior cruciate ligament (ACL) is one of the most common injured knee ligaments and at the same time, one of the most frequent injuries seen in the sport orthopaedic practice. Due to the clinical relevance of ACL injuries, numerous papers focussing on this topic including biomechanical-, basic science-, clinical- or animal studies, were published. The purpose of this study was to determine the most frequently cited scientific articles which address this subject, establish a ranking of the 50 highest cited papers and analyse them according to their characteristics. METHODS: The 50 highest cited articles related to Anterior Cruciate Ligament Injury were searched in Thomson ISI Web of Science® by the use of defined search terms. All types of scientific papers with reference to our topic were ranked according to the absolute number of citations and analyzed for the following characteristics: journal title, year of publication, number of citations, citation density, geographic origin, article type and level of evidence. RESULTS: The 50 highest cited articles had up to 1624 citations. The top ten papers on this topic were cited 600 times at least. Most papers were published in the American Journal of Sports Medicine. The publication years spanned from 1941 to 2007, with the 1990s and 2000s accounting for half of the articles (n = 25). Seven countries contributed to the top 50 list, with the USA having by far the most contribution (n = 40). The majority of articles could be attributed to the category "Clinical Science & Outcome". Most of them represent a high level of evidence. DISCUSSION: Scientific articles in the field of ACL injury are highly cited. The majority of these articles are clinical studies that have a high level of evidence. Although most of the articles were published between 1990 and 2007, the highest cited articles in absolute and relative numbers were published in the early 1980s. These articles contain well established scoring- or classification systems. CONCLUSION: The identification of important papers will help current clinicians and scientists to get an overview on past and current trends in that special field of ACL injury and provides a basis for both further discussion as well as future research.