Ambulatory knee biomechanics and muscle activity 2 years after ACL surgery: InternalBraceTM-augmented ACL repair versus ACL reconstruction versus healthy controls.

BACKGROUND: Little is known about knee mechanics and muscle control after augmented ACL repair. Our aim was to compare knee biomechanics and leg muscle activity during walking between the legs of patients 2 years after InternalBraceTM-augmented anterior cruciate ligament repair (ACL-IB) and between patients after ACL-IB and ACL reconstruction (ACL-R), and controls. METHODS: Twenty-nine ACL-IB, 27 sex- and age-matched ACL-R (hamstring tendon autograft) and 29 matched controls completed an instrumented gait analysis. Knee joint angles, moments, power, and leg muscle activity were compared between the involved and uninvolved leg in ACL-IB (paired t-tests), and between the involved legs in ACL patients and the non-dominant leg in controls (analysis of variance and posthoc Bonferroni tests) using statistical parametric mapping (SPM, P < 0.05). Means and 95% confidence intervals (CI) of differences in discrete parameters (DP; i.e., maximum/minimum) were calculated. RESULTS: Significant differences were observed in ACL-IB only in minimum knee flexion angle (DP: 2.4°, CI [-4.4;-0.5]; involved > uninvolved) and maximum knee flexion moment during stance (-0.07Nm/kg, CI [-0.13;-0.00]; involved < uninvolved), and differences between ACL-IB and ACL-R only in maximum knee flexion during swing (DP: 3.6°, CI [0.5;7.0]; ACL-IB > ACL-R). Compared to controls, ACL-IB (SPM: 0-3%GC, P = 0.015; 98-100%, P = 0.016; DP: -6.3 mm, CI [-11.7;-0.8]) and ACL-R (DP: -6.0 mm, CI [-11.4;-0.2]) had lower (maximum) anterior tibia position around heel strike. ACL-R also had lower maximum knee extension moment (DP: -0.13Nm/kg, CI [-0.23;-0.02]) and internal knee rotation moment (SPM: 34-41%GC, P < 0.001; DP: -0.03Nm/kg, CI [-0.06;-0.00]) during stance, and greater maximum semitendinosus activity before heel strike (DP: 11.2%maximum voluntary contraction, CI [0.1;21.3]) than controls. CONCLUSION: Our results suggest comparable ambulatory knee function 2 years after ACL-IB and ACL-R, with ACL-IB showing only small differences between legs. However, the differences between both ACL groups and controls suggest that function in the involved leg is not fully recovered and that ACL tear is not only a mechanical disruption but also affects the sensorimotor integrity, which may not be restored after surgery. The trend toward fewer abnormalities in knee moments and semitendinosus muscle function during walking after ACL-IB warrants further investigation and may underscore the importance of preserving the hamstring muscles as ACL agonists. LEVEL OF EVIDENCE: Level III, case-control study. TRIAL REGISTRATION: clinicaltrials.gov, NCT04429165 (12/06/2020).

Favorable Patient-Reported, Clinical, and Functional Outcomes 2 Years After ACL Repair and InternalBrace Augmentation Compared With ACL Reconstruction and Healthy Controls.

BACKGROUND: Recently, interest in anterior cruciate ligament (ACL) preservation and repair after proximal ACL tears has been resurrected. Although good clinical outcomes have been reported in the literature with adequate patient selection, to date detailed scientific evidence for the functional benefit of primary ACL repair with ligament augmentation is scarce. PURPOSE: To compare patient-reported, clinical, and functional outcomes in patients 2 years after ACL repair and InternalBrace augmentation (ACL-IB) with age- and sex-matched patients 2 years after ACL reconstruction (ACL-R) and with matched healthy controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: In total, 29 patients 2 years after ACL-IB, 27 sex- and age- matched patients 2 years after ACL-R (hamstring autografts), and 29 matched healthy controls were included. Patient-reported outcomes were assessed using the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, EQ-5D-5L, Tegner Activity Scale, and Anterior Cruciate Ligament Return to Sports after Injury scale. Surgery time was recorded. For clinical outcomes, range of motion and thigh and shank circumference were measured, and passive anterior translation was determined using the Rolimeter. Isokinetic muscle strength was measured using a Biodex dynamometer. The limb symmetry index (operated/contralateral or nondominant/dominant × 100), side-to-side differences (operated - contralateral, nondominant - dominant), and hamstring-quadriceps ratios were calculated for functional parameters. Failure and reoperation rates were not compared. RESULTS: Two years after surgery, patients treated with ACL-IB showed good to excellent patient-reported outcomes comparable with those of patients after ACL-R. Surgery time, including concomitant surgeries, was significantly shorter in the ACL-IB group (mean, 81 minutes) compared with the ACL-R group (mean, 97 minutes) (P = .024). Isokinetic muscle strength was comparable between patient groups without significant differences in extensor and flexor strength or in hamstring-quadriceps ratios. CONCLUSION: These results suggest that ACL-IB achieves comparable patient-reported, clinical, and functional outcomes with ACL-R at 2 years postoperatively and, after careful patient selection, should be considered as a valuable early treatment alternative for proximal ACL tears. REGISTRATION: NCT04429165 (ClinicalTrials.gov identifier).

A Novel Sensor-Based Application for Home-Based Rehabilitation Can Objectively Measure Postoperative Outcomes following Anterior Cruciate Ligament Reconstruction.

In order to successfully implement individualized patient rehabilitation and home-based rehabilitation programs, the rehabilitation process should be objectifiable, monitorable and comprehensible. For this purpose, objective measurements are required in addition to subjective measurement tools. Thus, the aim of this prospective, single-center clinical trial is the clinical validation of an objective, digital medical device (DMD) during the rehabilitation after anterior cruciate ligament reconstruction (ACLR) with regards to an internationally accepted measurement tool. Sixty-seven patients planned for primary ACLR (70:30% male-female, aged 25 years [21-32], IKDC-SKF 47 [31-60], Tegner Activity Scale 6 [4-7], Lysholm Score 57 [42-72]) were included and received physical therapy and the DMD after surgery. For clinical validation, combined measures of range of motion (ROM), coordination, strength and agility were assessed using the DMD in addition to patient-reported outcome measures (PROMs) at three and six months after ACLR. Significant correlations were detected for ROM (rs = 0.36-0.46, p < 0.025) and strength/agility via the single-leg vertical jump (rs = 0.43, p = 0.011) and side hop test (rs = 0.37, p = 0.042), as well as for coordination via the Y-Balance test (rs = 0.58, p ≤ 0.0001) regarding the IKDC-SKF at three months. Additionally, DMD test results for coordination, strength and agility (Y-Balance test (rs = 0.50, p = 0.008), side hop test (rs = 0.54, p = 0.004) and single-leg vertical jump (rs = 0.44, p = 0.018)) correlate significantly with the IKDC-SKF at six months. No adverse events related to the use of the sensor-based application were reported. These findings confirm the clinical validity of a DMD to objectively quantify knee joint function for the first time. This will have further implications for clinical and therapeutic decision making, quality control and monitoring of rehabilitation measures as well as scientific research.

Functional leg performance 2 years after ACL surgery: a comparison between InternalBrace™-augmented repair versus reconstruction versus healthy controls.

BACKGROUND: While clinical and patient-reported outcomes have been investigated in patients after InternalBrace™-augmented anterior cruciate ligament repair (ACL-IB), less is known regarding restoration of functional performance. We aimed to determine differences in functional performance within and between patients 2 years after ACL-IB, patients 2 years after ACL reconstruction (ACL-R), and healthy controls. MATERIALS AND METHODS: A total of 29 ACL-IB, 27 ACL-R (hamstring autograft), and 29 controls performed single-leg hop (maximum forward distance hop, SLH; side hop > 40 cm in 30 s, SH), proprioception (knee joint position sense at 30° and 60° flexion), and dynamic postural balance (Y Balance) tests. Differences were calculated within groups (side-to-side difference) and between the involved leg of patients and the non-dominant leg of controls, and were evaluated to predefined statistical (P < 0.05), clinically relevant, and methodological (smallest detectable change) thresholds. The number of exceeded thresholds represented no (0), small (1), moderate (2), or strong (3) differences. In addition, the relative number of participants achieving leg symmetry (≥ 90%) and normal performance (≥ 90% of the average performance of the non-dominant leg of controls) were compared between groups (chi-squared tests, P < 0.05). RESULTS: We observed no-to-moderate leg differences within ACL-IB (moderate difference in hops) and within ACL-R (moderate difference in knee proprioception), no leg differences between patient groups, no-to-small leg differences between ACL-IB and controls, and no leg differences between ACL-R and controls in functional performance. However, two patients in ACL-IB and ACL-R, respectively, passed the hop pretest only with their uninvolved leg, and fewer patients after ACL-IB and ACL-R than controls reached a leg symmetry and normal leg performance of controls in SLH (P < 0.001). CONCLUSIONS: Functional performance seems to be comparable 2 years postoperatively between ACL-IB and ACL-R for a specific subgroup of patients (i.e., proximal ACL tears, moderate activity level). However, the presumed advantage of comparable functional outcome with preserved knee structures after augmented ACL repair compared with ACL-R, and the tendency of both patient groups toward leg asymmetry and compromised single-leg hop performance in the involved legs, warrants further investigation. Level of Evidence Level III, case-control study. Trial registration clinicaltrials.gov, NCT04429165 (12/09/2020). Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT04429165 .

Distal femoral osteotomy for the valgus knee: indications, complications, clinical and radiological outcome.

INTRODUCTION: The aim of this study was to describe the indications and technical aspects of medial closing and lateral opening distal femoral osteotomy (MCDFO and LODFO) for patients with a valgus knee and to report clinical and radiological outcomes and complications. METHODS: Over 6 years, 28 DFOs (22 MCDFO, 6 LODFO) were performed in 22 Patients. In this cohort study, we retrospectively analyzed clinical and radiological outcome measures as well as complications. RESULTS: The median (range) age was 47 (17-63) years, height 1.68 (1.56-1.98) m, body mass 80 (49-105) kg, and body mass index (BMI) 27.4 (18.6-37.0) kg/m2. The clinical follow-up was 21 (7-81) months, the need for total or unicompartmental knee arthroplasty (TKA/UKA) and hardware removal was followed up for 59 (7-108) months postoperatively. Preoperatively, hip-knee-ankle angle (HKA, negative values denote varus) was 7.0 (2.0-13.0)°, mechanical lateral distal femoral angle (mLDFA) was 83.7 (79.9-88.2)°, and mechanical proximal tibial angle (MPTA) was 89.0 (86.6-94.5)°. Postoperatively, HKA was -1.3 (-9.0-1.2)° and mLDFA was 90.8 (87.3-97.3)°. The incidence of minor and major complications was 25% and 14%, the incidence of delayed and nonunion was 18% and 4%, respectively. At the last follow-up, 18% of the patients had pain at rest, 25% during activities of daily living, and 39% during physical activity, and 71% were satisfied with the outcome. 7% of the cases received a TKA/UKA, 71% received a hardware removal. CONCLUSION: DFO is a reasonable treatment for lateral osteoarthritis in younger patients to avoid disease progression and the need for an UKA/TKA. However, there is a long rehabilitation time, a considerable risk for complications, and a high need for hardware removal. While many patients experienced symptoms at the long-term follow-up, most were satisfied with the outcome. Appropriate patient information is essential. Level of evidence Level IV, Case Series. Trial registration number NCT04382118, clinicaltrials.gov, May 11, 2020.

Development and validation of a clinical prediction model for return to work after arthroscopic anterior crucial ligament reconstruction.

BACKGROUND: Occupational reintegration after anterior cruciate ligament (ACL) rupture is an important clinical issue including economic and health-related perspectives. This study aims to develop and validate a clinical prediction model of return to work in patients with ACL reconstruction surgery considering evidence-based clinical, anthropometric and occupational factors. METHODS: Data of 562 patients with an ACL rupture receiving an arthroscopic ACL reconstruction were used for analysis. A model for the binary outcome of experiencing an inability to work period of less or more than 14 days (model 1), and a model for finding predictor variables that are linearly associated with a continuous longer inability to work period of over 14 days (model 2) was calculated. Pre-operative determinants including patient characteristics and peri-operative factors were used as predictors for both models. RESULTS: For model 1, the highest increase in odds was observed for the occupational type of work, followed by injury of the medial collateral ligament together with partial weight bearing. Small protective effects were observed for female sex, meniscal suture and work with light occupational strain. The type of occupational work, together with revision surgery, a longer duration of limited range of motion and the presence of cartilage therapy were risk factors for longer inability to work. Discrimination and calibration statistics were satisfactory in internal validation. CONCLUSION: Within the framework of clinical consideration, these prediction models will serve as an estimator for patients, their treating physicians and the socioeconomic partners to forecast the individual cost and benefit of ACL injury.

High tibial osteotomy effectively redistributes compressive knee loads during walking.

The objectives of this study were to estimate pre- and postoperative lower limb kinematics and kinetics and knee intra-articular forces during gait using musculoskeletal modeling in a cohort of patients with knee osteoarthritis (OA) undergoing high tibial osteotomy (HTO), compare these to controls, and determine correlations between changes in these parameters and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores after HTO. Sixteen patients with isolated, symptomatic medial compartment knee OA completed pre- and postoperative gait analysis (mean follow-up time: 8.6 months). Sixteen age- and sex-matched asymptomatic volunteers participated as controls. Musculoskeletal modeling was used to evaluate lower limb joint moments and knee contact forces during gait. While HTO had limited influence on sagittal plane kinematics and moments, significant changes in the load distribution at the knee after HTO were observed with a lower postoperative compressive load on the medial compartment during midstance and a higher compressive load on the lateral compartment during early and late stance. Moreover, the lateral shear force in midstance was significantly lower after HTO. Changes in the external knee adduction moment (KAM) did not always coincide with reductions in the knee compressive force in the medial compartment. Biomechanical changes did not correlate with improvements in KOOS subscores. Hence, HTO effectively unloaded the medial compartment by redistributing part of the overall compressive force to the lateral compartment during gait with limited influence on gait function. The KAM may not adequately describe compartmental load magnitude or changes induced by interventions at the compartment level. Clinical trial registration: ClinicalTrials. gov Identifier-NCT02622204. Clinical significance: This study provides important evidence for changes in joint level loads after corrective osteotomy as joint preserving surgery and emphasizes the need for additional biomechanical outcomes of such interventions.

Dynamic versus static medial patellofemoral ligament reconstruction technique in the treatment of recurrent patellar dislocation: a randomized clinical trial protocol.

BACKGROUND: The redislocation rate of conservatively treated patella instability is high. One of the leading surgical strategies is medial patellofemoral ligament reconstruction. Over-tensioning is one of the most challenging complications in static medial patellofemoral ligament reconstruction as the graft used for reconstruction is isometric and the anatomical MPFL is a mostly dynamic structure. As an alternative to established static reconstruction techniques, dynamic graft techniques have been introduced for stabilizing the patella with the aim of providing a more physiological reconstruction of the medial patellofemoral ligament. To date, data on clinical outcomes are scarce and on biomechanical outcomes of the dynamic MPFL reconstruction are lacking. Here, we present the protocol of a randomized clinical trial for comparing clinical and biomechanical outcomes of dynamic versus static medial patellofemoral ligament reconstruction. METHODS: This study is a prospective, single blinded, randomized, multicenter, multimodal (clinical and biomechanical) clinical trial. Patients with recurrent patella dislocation requiring isolated MPFL reconstruction will be recruited and randomized to the dynamic or static reconstruction technique. Participants will be followed up for 2 years with a total of five follow-ups. Preoperative magnetic resonance imaging, upright radiographs, surgical reports and patient records will be evaluated, and clinical and functional outcomes will be measured. Patient-reported knee function and anterior knee pain as assessed with the Kujala score will serve as primary outcome. For biomechanical outcome, pre- and postoperative evaluations will be performed to assess isokinetic muscle strength, gait asymmetry, joint kinematics and kinetics, and timing of muscle activity. DISCUSSION: The results of the study will clarify whether the reported surgery success for patella stabilization via dynamic MPFL reconstruction is due to muscle contraction or to the passive tenodesis effect combined with clinical outcome measures. With this study, we will provide much needed information on knee biomechanics after dynamic versus static MPFL reconstruction to provide evidence to support orthopedic surgeons in evidence-based decision-making in their quest for surgical techniques most favorable for their patients. Trial registration The study protocol was registered at clinicaltrials.gov (NCT04849130). Registered 19 April 2021, https://clinicaltrials.gov/ct2/show/NCT04849130 .

RetroBRACE: clinical, socioeconomic and functional-biomechanical outcomes 2 years after ACL repair and InternalBrace augmentation in comparison to ACL reconstruction and healthy controls-experimental protocol of a non-randomised single-centre comparative study.

INTRODUCTION: Despite good clinical outcomes reported in the literature, to date, scientific evidence for the functional and biomechanical benefit of primary anterior cruciate ligament (ACL) repair with augmentation is scarce. We present an experimental protocol for a detailed multimodal (clinical, socioeconomic, functional and biomechanical) comparative study in patients after primary ACL repair and InternalBrace augmentation, patients after ACL reconstruction and healthy controls. METHODS AND ANALYSIS: In this non-randomised single-centre comparative study with prospective data collection with three arms (patients 2 years after ACL repair and InternalBrace augmentation; patients 2 years after ACL reconstruction using hamstring autografts; and healthy controls), 30 participants per study arm will be included. The study is designed as non-inferiority study with three arms. Required sample size was estimated based on data reported in the literature on muscle strength, proprioception and balance parameters, resulting in at least 28 participants per group. Outcome parameters include patient-reported outcome measures (EQ-5D-5L, Tegner Activity Scale, Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee and ACL-Return to Sports Injury Scale), socio-economic parameters, anterior tibial translation, range of motion and functional-biomechanical data of the lower extremities. Functional-biomechanical parameters include proprioception, isokinetic muscle strength, single-leg balance, walking, running and single-leg hops with additional lower extremity 3D joint kinematics and kinetics and muscle activity. These parameters will be compared between limbs in patients, between groups and to the current literature. ETHICS AND DISSEMINATION: The results of this study will be disseminated through peer-reviewed publications and presentations at national and international conferences. Ethical approval was obtained by the regional ethics board (Ethics Committee Northwest Switzerland EKNZ 2020-00551), and the study is registered at clinicaltrials.gov.Trial registration numberNCT04429165.

Cementing technique for total knee arthroplasty in cadavers using a pastry bone cement.

BACKGROUND: In cemented primary total knee arthroplasty (TKA), aseptic loosening remains a major cause for failure. Cementing techniques and characteristics of a chosen cement play a key role for good fixation and implant survival. A pastry bone cement was developed to facilitate the cement preparation and to rule out most of preparation-associated application errors. The pastry bone cement was compared to a conventional polymethyl methacrylate cement in a TKA setting. METHODS: Standardized implantations of total knee endoprostheses were performed in bilateral knee cadavers to investigate handling properties, variables of cement application, working time, and temperature development. Mechanical aspects and cementation quality were assessed by pull-out trials and microscopic interface analysis. RESULTS: Both cements expressed similar characteristics during preparation and application, only the curing time of the pastry cement was about 3 min longer and the temperature peak was lower. Fractures of the conventional cement specimens differed from the pastry cement specimens in the tibial part, while no differences were found in the femoral part. Penetration depth of the pastry cement was similar (tibia) or deeper (femur) compared to the conventional cement. CONCLUSIONS: The pastry cement facilitates the feasibility of cemented TKA. The pre-clinical tests indicate that the pastry bone cement fulfills the requirements for bone cement in the field of knee arthroplasty. A clinical trial is needed to further investigate the approach and ensure patient safety.

Lateral trochlear lengthening osteotomy.

INTRODUCTION: The purpose of this study was to describe the indications and technical aspects as well as evaluate the clinical and functional outcome of lengthening osteotomy of the lateral trochlear ridge in patients with patellofemoral pain and/or patella instability and presence of trochlear dysplasia Dejour type A or lack of Dejour type dysplasia and short lateral articular trochlea. MATERIALS AND METHODS: Six consecutive adult patients were treated with a lateral trochlear lengthening osteotomy. Five patients received a concomitant medial patellofemoral ligament reconstruction. Three patients had prior patella stabilization surgeries. Trochlea dysplasia (Dejour classification), Caton-Dechamps index, tibial tubercle trochlear groove (TT-TG) distance, patellar tilt and lateral condylar index were measured in preoperative MRIs. Clinical and functional evaluation included the Kujala Anterior Knee Pain Scale, the Lysholm Knee Score, the Tegner Activity Score, a subjective evaluation form and isokinetic muscle strength. RESULTS: Four patients had a Dejour type A dysplasia, two patients had no dysplasia. The mean (range) Caton-Dechamps index was 1.09 (0.95-1.16), TT-TG distance 10.9 mm (9.2-15.6 mm), patellar tilt 15° (4-32°) and lateral condylar index 82.0% (74-90%). One patient was lost to follow up, all others were followed for 2-5 years. All patients were satisfied with the clinical outcome. The Lysholm score increased from 55 (37-79) to 89 (76-100), the Tegner activity score from 3.6 (2-6) to 5.6 (5-7). The Kujala score postoperative was 90 (75-96). Some but not all patients had full strength recovery compared to the contralateral leg. CONCLUSION: We recommend measuring the lateral condylar index and considering the indication of a lateral trochlear lengthening osteotomy as an additional or isolated procedure in selected patients with trochlear dysplasia Dejour type A or lack of dysplasia and short lateral articular trochlea depending on the extent of the patellar instability. LEVEL OF EVIDENCE: Level IV, Case Series. TRIAL REGISTRATION NUMBER: NCT04378491, clinicaltrials.gov, May 7, 2020.

Experimental-analytical approach to assessing mechanosensitive cartilage blood marker kinetics in healthy adults: dose-response relationship and interrelationship of nine candidate markers.

Purpose: To determine the suitability of selected blood biomarkers of articular cartilage as mechanosensitive markers and to investigate the dose-response relationship between ambulatory load magnitude and marker kinetics in response to load.  Methods: Serum samples were collected from 24 healthy volunteers before and at three time points after a 30-minute walking stress test performed on three test days. In each experimental session, one of three ambulatory loads was applied: 100% body weight (BW); 80%BW; 120%BW. Serum concentrations of COMP, MMP-3, MMP-9, ADAMTS-4, PRG-4, CPII, C2C and IL-6 were assessed using commercial enzyme-linked immunosorbent assays. A two-stage analytical approach was used to determine the suitability of a biomarker by testing the response to the stress test (criterion I) and the dose-response relationship between ambulatory load magnitude and biomarker kinetics (criterion II).  Results. COMP, MMP-3 and IL-6 at all three time points after, MMP-9 at 30 and 60 minutes after, and ADAMTS-4 and CPII at immediately after the stress test showed an average response to load or an inter-individual variation in response to load of up to 25% of pre-test levels. The relation to load magnitude on average or an inter-individual variation in this relationship was up to 8% from load level to load level. There was a positive correlation for the slopes of the change-load relationship between COMP and MMP-3, and a negative correlation for the slopes between COMP, MMP-3 and IL-6 with MMP-9, and COMP with IL6.  Conclusions: COMP, MMP-3, IL-6, MMP-9, and ADAMTS-4 warrant further investigation in the context of articular cartilage mechanosensitivity and its role in joint degeneration and OA. While COMP seems to be able to reflect a rapid response, MMP-3 seems to reflect a slightly longer lasting, but probably also more distinct response. MMP-3 showed also the strongest association with the magnitude of load.

Correction to: No added value using SPECT/CT to analyze persistent symptoms after anterior cruciate ligament reconstruction.

The shared first authorship of Christian Egloff, MD and Lukas Huber was always planned and correctly acknowledged.

No added value using SPECT/CT to analyze persistent symptoms after anterior cruciate ligament reconstruction.

PURPOSE: To evaluate the diagnostic and clinical value of SPECT/CT compared to the standard algorithm for patients with persistent symptoms after anterior cruciate ligament reconstructions. The standard algorithm uses clinical information, conventional radiographs, MRI and CT scan, while the trial algorithm uses the same information but SPECT/CT in addition. METHODS: In a diagnostic comparative trial three experienced surgeons evaluated 23 consecutive patients with persistent symptoms after ACL reconstruction using first standard and second the trial algorithm with a time interval. Each rater had to establish a diagnosis and therapeutic decision with each algorithm. On MRI, graft continuity, bone marrow edema, chondral and meniscal lesions, femoral notch osteophytes were evaluated. Bone tracer uptake in SPECT/CT was anatomically analyzed and compared with MRI findings. MRI findings and SPECT/CT tracer uptake were correlated using Spearman's rho test. RESULTS: Additional SPECT/CT analysis did not change diagnosis in any case and did not correlate with clinical graft integrity. Treatment decisions remained unchanged as well. Chondral lesions, arthritic changes, meniscal lesions, graft impingement are best visualized in MRI and showed correspondent tracer uptake in SPECT/CT. Tunnel position was well classified with standard CT scan and showed no correlation with SPECT/CT tracer uptake. CONCLUSION: Information derived by SPECT/CT in addition to the standard algorithm using clinical information, X-rays, MRI, and CT scan did not change the diagnosis or treatment plan. There is currently no justification to implement SPECT/CT for patients with persistent symptoms after anterior cruciate ligament reconstructions. LEVEL OF EVIDENCE: Level II: diagnostic comparative study.

Does patella alta lead to worse clinical outcome in patients who undergo isolated medial patellofemoral ligament reconstruction? A systematic review.

INTRODUCTION: The aim of this systematic review is to determine the effect of patella height on clinical outcomes after isolated MPFL reconstruction for patella instability. Our primary hypothesis is that patients with patella alta report similar outcomes after isolated MPFL reconstruction compared to patients with normal patella height. METHODS: A review of the literature was performed according to the PRISMA guidelines. PubMed, EMBASE, and the Cochrane Library were searched from inception to January 10th 2018. Studies were identified using synonyms for "medial patellofemoral ligament", "reconstruction" and "patella alta". RESULTS: The search resulted in 467 reports on PubMed, 175 on EMBASE and 3 on the Cochrane Library. We included and analyzed in detail six studies describing outcomes after isolated medial patellofemoral ligament reconstruction with regard to patellar height. We found that both patients with patella alta and normal patella height reported satisfactory outcomes after isolated medial patellofemoral ligament reconstruction. However, because of applied exclusion criteria in the included studies the total number of patients with severe patella alta was small (13/74 patients with patella alta, 18%). CONCLUSIONS: Based on the current literature we suggest that additional tibial tubercle distalisation is not mandatory in patients with mild patella alta (Caton-Deschamps Index 1.2-1.4). To assess the best indications for different surgical procedures for patients with patella instability future research is needed to develop a clear and uniform definition of relevant patella alta. LEVEL OF EVIDENCE: III.

Reduction Osteotomy of the Prominent Tibial Tubercle After Osgood-Schlatter Disease.

PURPOSE: To evaluate the functional and clinical outcome of a new closing-wedge osteotomy for the prominent tibial tubercle after Osgood-Schlatter disease. METHODS: Between 2010 and 2014, 7 consecutive adults (mean age, 28.6 years; range, 26-35 years) were treated by closing-wedge reduction osteotomy of a painful tibial tubercle. All patients had prior nonsurgical and surgical treatment. Preoperative and postoperative tubercular prominence, Caton-Deschamps index for patellar height, the Kujala Anterior Knee Pain Scale, Lysholm Knee Score as well as visual analog scale score and Tegner activity scores were recorded. RESULTS: Mean follow-up after reduction osteotomy was 31.3 months (27-41 months). The bony prominence of the tibial tubercle was significantly reduced (mean 8 mm, P < .001) and the Caton-Deschamps index was lowered from 1.29 to 1.09 (P < .001). From preoperative to last follow-up, the Kujala Anterior Knee Pain Scale increased from 54.71 preoperative to 84.71 (P < .001); the Lysholm Knee Score improved from 72.42 to 94.14 (P < .001); the Tegner activity score increased from 3.1 to 5.7 (P < .001), whereas the visual analog scale significantly decreased from 5.8 to 1.2 (P < .001). No complications were recorded, and all patients were satisfied with clinical outcome. CONCLUSIONS: Closing-wedge osteotomy of the tibial tubercle effectively reduced the bony prominence after Osgood-Schlatter disease and consecutively improved the outcome in terms of knee pain and function. Thus, we can recommend this procedure in selected patients. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The painful primary hip replacement - review of the literature.

Total hip replacement is one of the most successful surgical procedures of the 20th century (World Health Organisation). The success rate is dependent on the chosen endpoint. Evaluation of the outcome in joint replacement surgery has shifted from the revision rate toward patient satisfaction and quality of life. Patient satisfaction is reported to be up to 96% 16 years postoperatively, but the prevalence of groin pain after conventional total hip replacement ranges from 0.4% to 18.3% and activity-limiting thigh pain is still an existing problem linked to the femoral component of uncemented hip replacement in up to 1.9% to 40.9% of cases in some series. The aim of our article is to review the aetiology, diagnostic procedures and treatment of the painful primary total hip replacement. We discuss the most relevant intrinsic and extrinsic aetiological factors responsible for chronic pain after total hip arthroplasty focusing on comparative studies and randomised controlled trials including diagnostics and management. Detailed analysis of history, clinical examination, imaging and laboratory tests are required prior to any revision for painful total hip arthroplasty. Revision surgery without knowing the underlying pathology should be avoided.

Changes of density distribution of the subchondral bone plate after supramalleolar osteotomy for valgus ankle osteoarthritis.

CT-osteoabsorptiometry (CT-OAM) has been used to visualize subchondral bone plate density distribution regarding to its mineralization. The purpose of this study was to display and analyze the density distribution of the subchondral bone plate before and after supramalleolar realignment osteotomies. We retrospectively analysed pre- and postoperative CT images of nine consecutive patients with post-traumatic unilateral valgus ankle OA. The distribution charts of CT-OAM scans were quantitatively analyzed for subchondral bone plate density distribution. VAS for pain and the Tegner activity scale were used to assess clinical outcome. At a mean follow-up of 20 ± 5.6 months (range 13-27), we observed a significant pre- to postoperative decrease of the mean high-density area ratio in tibia (lateral and posterior area) (p ≤ 0.05) and the talus (lateral area) (p ≤ 0.05). Pairwise comparison between the pre- and postoperative mineralization at the articular surface showed a significant decrease of the high-density area ratio for the tibia and the talus. The VAS decreased from 6.2 ± 0.9 pre- to 2.8 ± 0.9 postoperatively (p = 0.027), and the Tegner score inclined from 4.5 ± 1.1 preoperatively to 5.3 ± 0.7 after surgery (p = 0.082). The tibial and talar subchondral bone plate density, regarding to its mineralization, decreased after supramalleolar medial closing wedge osteotomy in patients with valgus ankle OA. The results of this study suggest that realignment surgery may decrease peak bone density areas corresponding to the alignment correction and contribute to a homogenization of the subchondral bone plate mineralization.