Direct contact and very rapid valgus distortion characterise the injury mechanism of anterior cruciate ligament ruptures in judo.

PURPOSE: To analyse anterior cruciate ligament (ACL) rupture (ACLR) injury mechanisms in competitive judo using systematic video analysis, focusing on contact situations and biomechanics. METHODS: Seventeen videos of judo competitions wherein athletes developed ACLRs were included and retrospectively evaluated by five analysts. In all videos, the moment of initial contact and the index frame were defined. The judo techniques leading to the injury; the occurrence of direct contact, indirect contact or noncontact mechanisms; the time interval between the initial contact and index frame; the positions of the hip, knee and foot in relation to the initial contact and index frame; and the balance status during the initial contact and index frame were recorded. RESULTS: Eleven (65%) of ACLRs in judo involved direct contact. The mean time interval between initial contact and index frame was 15 ± 22 ms. Thirteen (77%) athletes were not balanced at initial contact. In the index frame, the hip was abducted in all cases and in combination with internal rotation in 12 (71%) cases. From initial contact to index frame, hip flexion increased in all cases; at index frame, the knee joint was internally rotated relative to the trunk in 12 (71%) cases, and the knee flexion angles increased from the initial contact. In the index frame, the foot was externally rotated relative to the knee in 12 (71%) cases, and severe valgus development of the knee with valgus collapse was observed in 14 (82%) cases. CONCLUSIONS: A direct attack on the knee was the most common injury mechanism observed. Valgus distortion appears to be the most important component of the mechanism of injury. With this knowledge, 'modified defence reactions' for specific judo techniques can be developed to reduce the injury risk. LEVEL OF EVIDENCE: Level IV.

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment.

PURPOSE: The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS: For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE: Level V.

The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction. METHODS: In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not. RESULTS: At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers." CONCLUSIONS: The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.

Editorial Commentary: Traumatic and Atraumatic Meniscal Root Injuries Can Occur Both Medially and Laterally: No Rule Without Exceptions!

It took a long time for meniscal root injuries to slowly gain scientific and clinical attention some 40 years after the first arthroscopic meniscal resection. Medial root injuries are mostly degenerative in nature and often are associated with obesity and varus deformity. However, lateral root injuries are more commonly traumatic in origin and are associated with anterior cruciate ligament injuries. But, there is no rule without an exception. Laterally, there are isolated root injuries without anterior cruciate ligament involvement and also nontraumatic root injuries that can be associated with a valgus leg axis. Traumatic medial root injuries, on the other hand, occur in the context of knee dislocations. Therefore, the therapeutic concepts should not be based strictly on the localization medial or lateral but on the etiology, traumatic and not traumatic. Even though it has been shown that many patients benefit from refixation of the meniscus root, it seems sensible to search for the etiology of nontraumatic root injuries and to integrate this into the therapeutic concept (e.g., additional osteotomy to correct the varus or valgus deformity). However, the degenerative changes in the relevant compartment must also be taken into account. Recent biomechanical results on the influence of the meniscotibial (medial) or meniscofemoral (lateral) ligaments on extrusion are also relevant with regard to the success of root refixation. These results can provide the rationale for carrying out additional centralization.

Quadriceps and hamstring anterior cruciate ligament reconstruction differ only marginally in function after the rehabilitation: a propensity score-matched case-control study.

PURPOSE: To determine potential quadriceps versus hamstring tendon autograft differences in neuromuscular function and return to sport (RTS)-success in participants after an anterior cruciate ligament (ACL) reconstruction. METHODS: Case-control study on 25 participants operated on with an arthroscopically assisted, anatomic ipsilateral quadriceps femoris tendon graft and two control groups of 25 participants each, operated on with a semitendinosus tendon or semitendinosus-gracilis (hamstring) tendon graft ACL reconstruction. Participants of the two control groups were propensity score matched to the case group based on sex, age, Tegner activity scale and either the total volume of rehabilitation since reconstruction (n = 25) or the time since reconstruction (n = 25). At the end of the rehabilitation (averagely 8 months post-reconstruction), self-reported knee function (KOOS sum scores), fear of loading the reconstructed knee during a sporting activity (RSI-ACL questionnaire), and fear of movement (Tampa scale of kinesiophobia) were followed by hop and jump tests. Front hops for distance (jumping distance as the outcome) were followed by Drop jumps (normalised knee joint separation distance), and concluded by qualitative ratings of the Balanced front and side hops. Between-group comparisons were undertaken using 95% confidence intervals comparisons, effect sizes were calculated. RESULTS: The quadriceps case group (always compared with the rehabilitation-matched hamstring graft controls first and versus time-matched hamstring graft controls second) had non-significant and only marginal higher self-reported issues during sporting activities: Cohen's d = 0.42, d = 0.44, lower confidence for RTS (d = - 0.30, d = - 0.16), and less kinesiophobia (d = - 0.25, d = 0.32). Small and once more non-significant effect sizes point towards lower values in the quadriceps graft groups in the Front hop for distance limb symmetry values in comparison to the two hamstring control groups (d = - 0.24, d = - 0.35). The normalised knee joint separation distance were non-significantly and small effect sized higher in the quadriceps than in the hamstring groups (d = 0.31, d = 0.28). CONCLUSION: Only non-significant and marginal between-graft differences in the functional outcomes at the end of the rehabilitation occurred. The selection of either a hamstring or a quadriceps graft type cannot be recommended based on the results. The decision must be undertaken individually. LEVEL OF EVIDENCE: III.

Management after acute rupture of the anterior cruciate ligament (ACL). Part 1: ACL reconstruction has a protective effect on secondary meniscus and cartilage lesions.

PURPOSE: The aim of this consensus project was to validate which endogenous and exogenous factors contribute to the development of post-traumatic osteoarthritis and to what extent ACL (anterior cruciate ligament) reconstruction can prevent secondary damage to the knee joint. Based on these findings, an algorithm for the management after ACL rupture should be established. METHODS: The consensus project was initiated by the Ligament Injuries Committee of the German Knee Society (Deutsche Kniegesellschaft, DKG). A modified Delphi process was used to answer scientific questions. This process was based on key topic complexes previously formed during an initial face-to-face meeting of the steering group with the expert group. For each key topic, a comprehensive review of available literature was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Consensus was defined a-priori as eighty percent agreement. RESULTS: Of the 17 final statements, 15 achieved consensus, and 2 have not reached consensus. Results of the consensus were summarized in an algorithm for the management after ACL rupture (infographic/Fig. 2). CONCLUSION: This consensus process has shown that the development of post-traumatic osteoarthritis is a complex multifactorial process. Exogenous (primary and secondary meniscus lesions) and endogenous factors (varus deformity) play a decisive role. Due to the complex interplay of these factors, an ACL reconstruction cannot always halt post-traumatic osteoarthritis of the knee. However, there is evidence that ACL reconstruction can prevent secondary joint damage such as meniscus lesions and that the success of meniscus repair is higher with simultaneous ACL reconstruction. Therefore, we recommend ACL reconstruction in case of a combined injury of the ACL and a meniscus lesion which is suitable for repair. LEVEL OF EVIDENCE: Level V.

Management after acute injury of the anterior cruciate ligament (ACL), part 2: management of the ACL-injured patient.

PURPOSE: The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process. METHODS: For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient. LEVEL OF EVIDENCE: Level V.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III-indications for different clinical scenarios using the RAND/UCLA appropriateness method.

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.

Ultrasonography for quantitative assessment of knee joint effusions-useful tool for objective evaluation of rehabilitation progress?

PURPOSE: We sought to externally validate ultrasonography (US) for quantification of suprapatellar effusion size to improve diagnosis and individualised rehabilitation strategies in knee rehabilitation after anterior cruciate ligament reconstruction (ACLR) surgery. METHODS: US was performed on 35 patients as part of the ongoing CAMOPED study. Data were collected in ACLR and post surgery in defined intervals up to one year post-operation. The palpatory assessment was graded using the International Knee Documentation Committee (oIKDC). RESULTS: In a total of 164 sonographies, a strong correlation between palpatory and US effusion (r = 0.83, p < 0.01) with lower deviations in US quantification compared to palpatory quantification Y = 1.15 + 0.15* x was seen. Threshold values could be determined for the detection of effusions by palpation and for the differentiation between mild and moderate/severe effusions (effusion depth: 2.6 mm and resp. 5.8 mm, respectively). CONCLUSIONS: As demonstrated in this multicenter study, the size of suprapatellar effusions can be easily quantified with high accuracy using standardised bedside ultrasound. Especially in moderate to severe effusions, US provides a practical and reliable tool for outcome measurement superior to palpatory assessment with the goal of optimising individual recommendations during the rehabilitation course. Furthermore, for the first time, it has been possible to define sonographic threshold values for the detection of effusion and differentiation of mild vs. moderate/severe effusion by means of palpation.

Effect of anterior tibial bowing on measurement of posterior tibial slope on conventional X-rays.

PURPOSE: The posterior tibial slope (PTS) has different biomechanical effects on the knee. Especially in revision ACL reconstruction, a precise analysis is essential. Therefore, we investigate the influence of the anterior tibial bowing angle on the posterior slope measurement. Our hypothesis of the present study is that the short tibial X-rays underestimate the PTS in cases with increased anterior bowing of the tibia. METHODS: The PTS was measured on 162 true longitudinal radiographs of the complete tibia (lateral mechanic axis). The average age of the patients was 35.7 years (range 19-59 years) and the most common diagnosis was failed anterior cruciate ligament reconstruction. Using this X-ray, the slope on the short axis and the slope on the entire axis were measured. In addition, the angle of the anterior bowing was determined. RESULTS: The mean PTS for the lateral mechanic axis of the tibia was 10.6° (± 3.5) in contrast to 11.6° (± 3.5) for the short tibial axis. These two measurements differ significantly. (p < 0.001). The mean anterior tibial bowing angle on the lateral X-rays of the whole tibia was 2.3° (± 2.0). There is a significant positive, relationship between tibial bowing angle and PTS as referenced by the lateral mechanic axis (Spearman's correlation, r = 0.273 and p < 0.001). CONCLUSION: With increasing anterior tibial bowing, the posterior tibial slope on the short knee radiograph is underestimated compared to the slope measurement on the lateral mechanic axis.

Etiology of posterior meniscus root tears: medial vs. lateral.

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

The use of tranexamic acid reduces blood loss in osteotomy at knee level: a systematic review.

PURPOSE: Aim of this systematic review was to evaluate the literature regarding the effect of tranexamic acid (TXA) on the outcome after knee osteotomy. METHODS: A systematic literature search was carried out in various databases on studies on the use of tranexamic acid in osteotomies around the knee. Primary outcome criterion was the hemoglobin (drop). Secondary outcome criteria were total blood loss, drainage volume, adverse effects such as thromboembolic events, blood transfusions, wound complications and clinical scores. A meta-analysis was performed for quantitative measures. The present study was registered prospectively ( www.crd.york.ac.uk/PROSPERO ; no.: CRD42021229624). RESULTS: Seven studies with 584 patients (TXA group: 282 patients, non TXA group: 302 patients) Hemoglobin decrease (1.54 g/dl vs. 2.28 g/dl), blood loss (394.49 ml vs. 595.54 ml) and drainage volume (266.5 ml vs. 359.05 ml) were significantly less in the TXA group compared to the non TXA group. No thromboembolic event was noted in any study. In the non TXA group four blood transfusions were given. Eleven wound complications occurred in the non TXA group in comparison to two wound complications in the TXA group. CONCLUSIONS: The results of the present study show that the application of TXA reduces hemoglobin drop, blood loss and drainage volume. These effects could be responsible for the lesser rate of side effects after administration of TXA during knee osteotomy.

Germany has a high demand in meniscal allograft transplantation but is subject to health economic and legal challenges: a survey of the German Knee Society.

PURPOSE: To determine the current status and demand of meniscal allograft transplantation (MAT) in Germany among members of the German Knee Society (= Deutsche Kniegesellschaft; DKG). METHODS: An online survey was conducted between May 2021 and June 2021 and sent to all members of the DKG. The survey questionnaire consisted of 19 questions to determine the demand and technical aspects of MAT among the participants and to identify areas of improvement in MAT in Germany. RESULTS: Overall, 152 participants, 136 (89.5%) from Germany, 8 (5.3%) from Switzerland, 6 (4.0%) from Austria, and 2 (1.3%) from other countries completed the online survey, with the majority working in non-academic institutions. According to the regulations of the DKG, 87 (57.2%) participants were board certified as specialized knee surgeons and 97 (63.8%) worked primarily in the field of orthopedic sports medicine. MAT was considered clinically necessary in Germany by 139 (91.5%) participants. Patient age (83.6%), post-meniscectomy syndrome in isolated lateral (79.6%) and medial (71.7%) meniscus deficiency, and functional and athletic demands (43.4%) were the most important determinants to consider MAT in patients. Participants reported that reimbursement (82.9%), jurisdiction over the use of donor grafts (77.6%), and the availability of meniscal allografts (76.3%) are the main challenges in performing MAT in Germany. The most frequently used meniscal allograft types by 54 (35.5%) participants who had already performed MAT were fresh-frozen grafts (56.6%), peracetic acid-ethanol sterilized grafts (35.9%), and cryopreserved grafts (7.6%). Participants reported to perform suture-only fixation more often than bone block fixation for both medial (73.6% vs. 22.6%) and lateral (69.8% vs. 24.5%) MAT. CONCLUSION: More than 90% of the responding members of the DKG indicated that MAT is a clinically important and valuable procedure in Germany. Reimbursement, jurisdiction over the use of donor grafts, and the availability of meniscal allografts should be improved. This survey is intended to support future efforts to facilitate MAT in daily clinical practice in Germany. LEVEL OF EVIDENCE: Level V.

A systematic review about long-term results after meniscus repair.

PURPOSE: Aim of this systematic review was to analyze long-term results after meniscus refixation. METHODS: A systematic literature search was carried out in various databases on studies on long-term results after meniscus refixation with a minimum follow-up of 7 years. Primary outcome criterion was the failure rate. Secondary outcome criteria were radiological signs of osteoarthritis (OA) and clinical scores. RESULTS: A total of 12 retrospective case series (level 4 evidence) were identified that reported about failure rates of more than 7 years follow-up. There was no statistical difference in the failure rates between open repair, arthroscopic inside-out with posterior incisions and arthroscopic all-inside repair with flexible non-resorbable implants. In long-term studies that examined meniscal repair in children and adolescents, failure rates were significantly higher than in studies that examined adults. Six studies have shown minor radiological degenerative changes that differ little from the opposite side. The reported clinical scores at follow-up were good to very good. CONCLUSION: This systematic review demonstrates that good long-term outcomes can be obtained in patients after isolated meniscal repair and in combination with ACL reconstruction. With regard to the chondroprotective effect of meniscus repair, the long-term failure rate is acceptable. LEVEL OF EVIDENCE: IV.

Use of tranexamic acid in medial open wedge high tibial osteotomy.

PURPOSE: Aim of this study was to evaluate the effect of tranexamic acid (TXA) on the outcome after medial open wedge osteotomy. MATERIAL AND METHODS: A prospective non-randomized comparative study with 52 patients has been performed. In both treatment groups, the same surgical technique for the medial open wedge HTO was used. In group 1 (N: 26) the patients received 1 g TXA i.v. preoperatively, in group 2 (N: 26) no TXA was given. Primary outcome measure was the decrease in hemoglobin concentration. Secondary outcome criteria were postoperative pain, intraarticular effusion (measured by ultrasound), range of motion (ROM) at discharge, peri- and postoperative complications and the KOOS PS (pre- and postoperatively at 1 year follow up). RESULTS: Hemoglobin decrease was significantly less in the TXA group compared to the non TXA group. Postoperative pain and intraarticular effusion was also significantly lower and ROM at discharge was higher in the TXA group. There was no group difference in peri- and postoperative complications and the pre- and postoperatively KOOS PS. CONCLUSIONS: The results of the present study show the systemic application of 1 g TXA reduces hemoglobin drop and postoperative morbidity (pain, intraarticular effusion, and ROM) after tibial open wedge HTO.

Soaking ACL grafts in vancomycin solution (1 mg/ml) reduces the infection rate without increasing the risk for re-rupture and arthrofibrosis.

PURPOSE: The aim of the present study was to evaluate if the vancomycin (1 mg/ml) is effective for the prevention of septic arthritis after ACL reconstruction. The hypothesis was that local antibiotic prophylaxis by soaking ACL grafts in vancomycin results in significantly less infections than ACL reconstruction without local antibiosis. METHODS: In group 1, 636 patients who were operated between 1.9.2014 and 31.8.2016 received no local antibiotic treatment with vancomycin. In group 2, 536 patients who were operated between 1.9.2016 and 31.8.2018 received local antibiotic treatment with vancomycin (1 mg/ml). In this group the graft was soaked in the vancomycin solution for 10 min prior to graft passage and fixation. RESULTS: In group 1 (ACL reconstruction without vancomycin application), a postoperative infection was detected in ten patients (infection rate: 1.6%). In group 2 (ACL reconstruction with 1 mg/ml vancomycin), no postoperative infection was detected (infection rate: 0%). The statistical analysis showed a clear significant difference between the two groups (p = 0.002). The re-rupture rate and the rate of arthrofibrosis differed not significantly between the two treatment groups (p = 0.526). CONCLUSION: The results of the present study show that graft soaking in vancomycin (1 mg/ml) is effective for the prevention of septic arthritis after ACL reconstruction. LEVEL OF EVIDENCE: III.

Editorial Commentary: Medial and Lateral Meniscus Root Injuries Are Distinct, and Indications for Repair May Differ: Get Down to the Root of the Problem!

Medial and lateral root injuries are different clinical entities. Medial root injuries are of a degenerative nature and frequently are associated with obesity and varus deformity. Lateral root injuries, however, are more often of traumatic origin and usually associated with injuries to the anterior cruciate ligament. There is also a biomechanical difference between the 2 injuries. In the case of medial root injuries, the loss of circular hoop tension leads to an increase in peak contact pressure. In the case of lateral root lesions, the loss of hoop stress can be compensated for by an intact meniscofemoral ligament. Nevertheless, a repair also seems to make sense on the lateral meniscus, as the posterior root also has a stabilizing effect on the knee. The most suitable technique for lateral root repair depends on the type of lesion. A transtibial pull out repair is suitable for frequent avulsion injuries (type 1). In the case of type 2 injuries, which are also common, a side-to-side suture is an option.

Matrix-induced chondrogenesis is a valid and safe cartilage repair option for small- to medium-sized cartilage defects of the knee: a systematic review.

PURPOSE: The purpose of this study was to perform a systematic review of randomized controlled trials comparing the results of matrix-induced chondrogenesis with other therapies for local chondral lesions of the knee. METHODS: A systematic search for randomized controlled trials (RCT) about matrix-induced chondrogenesis for focal chondral lesions in the knee was performed according to the PRISMA guidelines. Data source was PubMed central, EMBASE and Google scholar. RESULTS: Five articles could be included, whereas two originated from the same study group. Three studies compared matrix-induced chondrogenesis to microfracture (MFx) only. One trial compared AMIC® to collagen-covered autologous chondrocyte implantation (ACI-C). One study assessed the improvements given by the combination of AMIC® with bone marrow aspirate concentrate (BMAC). In three studies, clinical improvements compared to baseline were seen at 2-year postoperation, irrespective of the technique used. After 5 years, one trial showed better results for the AMIC® group compared to MFx, including MRI defect filling. One study showed also good results after AMIC® with faster recovery for patients with AMIC® + BMAC 12 months postoperatively. CONCLUSION: Results of RCTs comparing matrix-induced chondrogenesis with other treatment options showed that matrix-induced chondrogenesis is a valid and safe cartilage repair option for small- to medium-sized cartilage defects of the knee. This one-stage surgical technique presents a good alternative for patients. LEVEL OF EVIDENCE: I.

Ultrasound-based examination of the medial ligament complex shows gender- and age-related differences in laxity.

PURPOSE: Ultrasound (US) examination of the medial joint space of the knee has played a subordinate diagnostic role up till now. The purpose of the present study was to describe mean values of medial joint width and to investigate the impact of gender, age, and body mass index (BMI) on medial joint laxity in healthy knees using modern, dynamic US in a standardized fashion in unloaded and standardized loaded conditions. METHODS: A total of 65 subjects with 79 healthy knees were enrolled in this study. All volunteers underwent clinical examination of the knee. The medial knee joint width was determined using US in a supine position at 0° and 30° of knee flexion in unloaded and standardized loaded (= 15 Dekanewton, daN) conditions using a specific device. Mean values were described and correlations between medial knee joint width and gender, age, and BMI were assessed. RESULTS: Thirty-two females and 33 males were enrolled in this study. The mean medial joint width in 0° unloaded was 5.7 ± 1.2 mm and 7.4 ± 1.4 mm loaded. In 30° of knee flexion, the mean medial joint width was 6.1 ± 1.1 mm unloaded and 7.8 ± 1.2 mm loaded. The average change between unloaded and loaded conditions in 0° was 1.7 ± 1.0 mm and in 30° 1.7 ± 0.9 mm. A significant difference between genders was evident for medial joint width in 0° and 30° of flexion in unloaded and loaded conditions (p < 0.05). With rising age, a significant increased change of medial joint space width between unloaded and loaded conditions could be demonstrated in 0° (p = 0.032). No significant correlation between BMI and medial joint width in US could be found. CONCLUSION: Mean values of medial joint width in unloaded and standardized loaded conditions using a fixation device could be demonstrated. Based on the results of this study, medial knee joint width in US is gender- and age-related in healthy knees. These present data may be useful for evaluating patients with acute or chronic pathologies to the medial side of the knee. LEVEL OF EVIDENCE: III.

A systematic review about telemedicine in orthopedics.

PURPOSE: Until now, the use of telemedical applications in orthopedics was limited to sparsely populated countries. However, due to the SARS-CoV-2 pandemic, interest in orthopedics in these procedures has increased significantly. The aim of this systematic review was to find out to what extent there is scientific evidence for the use of telemedicine in the orthopedic field. METHODS: A systematic literature search was carried out in various databases on randomized controlled trials (RCTs) on telemedical applications in orthopedics. RESULTS: Altogether, 14 articles were identified that reported about a total of eight RCTs of telemedical applications in orthopedics. Two RCTs were about a patient-to-doctor video consultation and six RCTs were about telerehabilitation after knee and hip arthroplasty (4 × knee arthroplasty, one hip and knee arthroplasty, one hip arthroplasty). For the majority of outcome parameters evaluated, there were no significant differences between the study groups. The cost effectiveness of videoconsultations depended on the workload (number of patient consultations) as well as the effectiveness of telerehabilitation on the distance of the patient's home to the health care center (30 km round-trip). CONCLUSION: There is sufficient evidence to recommend the use of telemedical methods in orthopedics. However, more research is necessary to further expand the possibilities of telemedical methods with regard to physical examination.