Daratumumab during Myeloma Induction Therapy Is Associated with Impaired Stem Cell Mobilization and Prolonged Post-Transplant Hematologic Recovery.

Daratumumab is being increasingly integrated into first-line multiple myeloma (MM) induction regimens, leading to improved response depth and longer progression-free survival. Autologous stem cell transplantation (ASCT) is commonly performed as a consolidation strategy following first-line induction in fit MM patients. We investigated a cohort of 155 MM patients who received ASCT after first-line induction with or without daratumumab (RVd, n = 110; D-RVd, n = 45), analyzing differences in stem cell mobilization, apheresis, and engraftment. In the D-RVd group, fewer patients successfully completed mobilization at the planned apheresis date (44% vs. 71%, p = 0.0029), and more patients required the use of rescue plerixafor (38% vs. 28%, p = 0.3052). The median count of peripheral CD34+ cells at apheresis was lower (41.37 vs. 52.19 × 106/L, p = 0.0233), and the total number of collected CD34+ cells was inferior (8.27 vs. 10.22 × 106/kg BW, p = 0.0139). The time to recovery of neutrophils and platelets was prolonged (12 vs. 11 days, p = 0.0164; and 16 vs. 14 days, p = 0.0002, respectively), and a higher frequency of erythrocyte transfusions (74% vs. 51%, p = 0.0103) and a higher number of platelet concentrates/patients were required (4 vs. 2; p = 0.001). The use of daratumumab during MM induction might negatively impact stem cell mobilization and engraftment in the context of ASCT.

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.

Malrotated lateral knee radiographs do not allow for a proper assessment of medial or lateral posterior tibial slope.

PURPOSE: The aim of this study was to investigate whether malrotation of lateral knee radiographs influences posterior tibial slope (PTS) measurements. METHODS: Lateral knee radiographs of all patients who underwent knee surgery at a single institution between June 2022 and January 2023 and received multiple lateral knee radiographs were included. Radiographs were categorised as malrotated lateral knee radiographs or lateral knee radiographs based on the radiographic distance between the medial and lateral posterior femoral condyles. Medial PTS (MPTS) and lateral PTS (LPTS) were evaluated on malrotated lateral knee radiographs and lateral knee radiographs and compared using the paired t test. Intra- and interrater reliability between four raters were assessed for MPTS and LPTS measurements. RESULTS: A total of 92 lateral knee radiographs (46 pairs of malrotated lateral knee radiographs and lateral knee radiographs; 50.0% right side) from 46 patients (33.2 ± 12.4 years, 69.6% male) were included. Mean posterior femoral condyle distance in malrotated lateral knee radiographs was 8.1 ± 4.4 mm. Overall, MPTS and LPTS were significantly higher on malrotated lateral knee radiographs versus lateral knee radiographs (medial: 10.5 ± 3.2° vs. 9.7 ± 3.5°, p < 0.05; lateral: 10.6 ± 3.4° vs. 9.7 ± 3.3°, p < 0.05). Mean absolute difference between MPTS and LPTS on malrotated lateral knee radiographs versus lateral knee radiographs were |1.9| ± |1.5|° and |2.0| ± |1.8|°, respectively. Intrarater reliability was 'moderate' and interrater reliability was 'good' for both MPTS and LPTS. CONCLUSION: Malrotation of lateral knee radiographs led to a significant distortion of both the MPTS and LPTS. In clinical practice, attention should be placed on the (mal)rotation of lateral knee radiographs, especially in patients for whom a slope-correcting osteotomy is being discussed. LEVEL OF EVIDENCE: Level IV.

Bilateral juvenile osteochondrosis dissecans in monozygotic twins: a case report.

INTRODUCTION: The etiology of osteochondrosis dissecans (OCD), a chondropathy associated with detachment of the subchondral bone and the overlaying cartilage, is not yet fully understood. While repetitive physical exercise-related stress is usually assumed to be the main risk factor for the occurrence of OCD, genetic predisposition could have an underestimated influence on the development of the disease. CASE REPORT: We report a case of monozygotic twins with almost identical stages of bilateral osteochondrosis dissecans of the knee joint. In both patients, initially, a unilateral lesion occurred; despite restricted physical exercise, in the further course of the disease a lesion also developed on the contralateral side. While the lesion found most recently demonstrated an ongoing healing process at a 6-month follow-up, the other three lesions showed a natural course of healing under conservative treatment with significant clinical as well as radiological improvements after one year and complete consolidation in magnetic resonance imaging (MRI) after 2 years. CONCLUSION: There could be a genetic component to the development of OCD, although this has not yet been proven. Based on a two-year MRI follow-up, we were able to show the self-limiting characteristics of juvenile osteochondrosis dissecans.

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.

[Influence of the bony alignment on the ligaments of the knee joint]. / Einfluss des knöchernen Alignments auf den Bandapparat des Kniegelenks.

In recent years biomechanical and clinical studies have shown that the three-dimensional bony alignment of the lower extremities has a relevant influence on the ligamentous structures of the knee and consequently on the stability of the knee joint. Therefore, in the case of pathological ligamentous damage of the knee joint, a possible malalignment must always be thoroughly evaluated and if necessary, included in the treatment planning. Varus malalignment plays an important role especially with respect to the cruciate ligaments as well as the posterolateral ligamentous structures and has been identified as a significant risk factor for failure after surgical reconstruction of these ligamentous structures. Similar data have also been published for valgus malalignment particularly with respect to its negative influence on the anterior cruciate ligament and the medial capsuloligamentous complex. Alignment deviations in the sagittal plane, especially the inclination of the tibial articular surface (slope), have been extensively investigated in several recent studies. It has been demonstrated that the tibial slope has a relevant influence on the anteroposterior stability of the knee joint and hence on the cruciate ligaments. First clinical studies on the surgical correction of the axis in selected patients showed very promising results with the potential of protecting ligament reconstructions against repeated failure; however, further data especially regarding the importance and the exact indications for an additional alignment correction are necessary.

The Posterior Tibial Slope Is Not Associated With Graft Failure and Functional Outcomes After Anatomic Primary Isolated Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Biomechanical studies have shown that an increased medial posterior tibial slope (MPTS) may affect anteroposterior knee laxity and tibial shear forces, ultimately increasing the risk for graft failure after anterior cruciate ligament (ACL) reconstruction. Previous clinical studies have, however, reported inconclusive results. PURPOSE: The purpose of this study was to evaluate the relationship between the MPTS and graft failure as well as functional outcomes after anatomic primary isolated ACL reconstruction using a hamstring tendon autograft. It was hypothesized that an increased MPTS would be associated with a higher ACL graft failure rate. Furthermore, a higher MPTS would negatively correlate with functional outcomes in patients without ACL graft failure. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Consecutive patients who underwent isolated primary ACL reconstruction with an anteromedial portal drilling technique between January 2011 and December 2019 were retrospectively reviewed. The MPTS was measured on preoperative lateral knee radiographs. At a minimum of 24 months postoperatively, the ACL graft failure rate and patient-reported outcome measures (PROM; International Knee Documentation Committee subjective knee form, Lysholm score, Tegner Activity Scale, visual analog scale for pain and subjective instability) were evaluated. Differences in the MPTS between patients with and without ACL graft failure as well as the frequency of graft failure between those with an MPTS <12° and those with an MPTS ≥12° were assessed for statistical significance. Binary logistic regression analysis was performed to stratify the risk of graft failure with the following variables: MPTS, age at surgery, and sex. Correlation analysis was performed to evaluate the relationship between the MPTS and PROM in patients without ACL graft failure. RESULTS: In total, 326 patients were included (median follow-up, 71.0 months [IQR, 49.0-104.0 months]). There was no significant difference in the MPTS between patients with and without graft failure (10.6°± 3.2° vs 11.2°± 2.8°, respectively; P = .264). Additionally, there was no significant difference in the frequency of graft failure between patients with an MPTS <12° and those with an MPTS ≥12° (15.6% vs 16.5%, respectively; P = .835). Binary logistic regression showed that younger age at the time of surgery (odds ratio, 1.069 [95% CI, 1.031-1.109]) was associated with graft failure; sex and MPTS were not associated with graft failure. In patients without ACL graft failure, there was no significant correlation between the MPTS and PROM. CONCLUSION: In patients who underwent anatomic primary isolated ACL reconstruction, an increased MPTS was not associated with a higher rate of graft failure or inferior functional outcomes. Younger age was a significant nonmodifiable risk factor for ACL graft failure.

Physiological Tensioning During Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears May Be Important for Improvement in Shoulder Kinematics.

BACKGROUND: Lower trapezius transfer (LTT) has been proposed for restoring the anteroposterior muscular force couple in the setting of an irreparable posterosuperior rotator cuff tear (PSRCT). Adequate graft tensioning during surgery may be a factor critical for sufficient restoration of shoulder kinematics and functional improvement. PURPOSE/HYPOTHESIS: The purpose was to evaluate the effect of tensioning during LTT on glenohumeral kinematics using a dynamic shoulder model. It was hypothesized that LTT, while maintaining physiological tension on the lower trapezius muscle, would improve glenohumeral kinematics more effectively than undertensioned or overtensioned LTT. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 10 fresh-frozen cadaveric shoulders were tested using a validated shoulder simulator. Glenohumeral abduction angle, superior migration of the humeral head, and cumulative deltoid force were compared across 5 conditions: (1) native, (2) irreparable PSRCT, (3) LTT with a 12-N load (undertensioned), (4) LTT with a 24-N load (physiologically tensioned according to the cross-sectional area ratio of the lower trapezius muscle), and (5) LTT with a 36-N load (overtensioned). Glenohumeral abduction angle and superior migration of the humeral head were measured using 3-dimensional motion tracking. Cumulative deltoid force was recorded in real time throughout dynamic abduction motion by load cells connected to actuators. RESULTS: Physiologically tensioned (Δ13.1°), undertensioned (Δ7.3°), and overtensioned (Δ9.9°) LTT each significantly increased the glenohumeral abduction angle compared with the irreparable PSRCT (P < .001 for all). Physiologically tensioned LTT achieved a significantly greater glenohumeral abduction angle than undertensioned LTT (Δ5.9°; P < .001) or overtensioned LTT (Δ3.2°; P = .038). Superior migration of the humeral head was significantly decreased with LTT compared with the PSRCT, regardless of tensioning. Physiologically tensioned LTT resulted in significantly less superior migration of the humeral head compared with undertensioned LTT (Δ5.3 mm; P = .004). A significant decrease in cumulative deltoid force was only observed with physiologically tensioned LTT compared with the PSRCT (Δ-19.2 N; P = .044). However, compared with the native state, LTT did not completely restore glenohumeral kinematics, regardless of tensioning. CONCLUSION: LTT was most effective in improving glenohumeral kinematics after an irreparable PSRCT when maintaining physiological tension on the lower trapezius muscle at time zero. However, LTT did not completely restore native glenohumeral kinematics, regardless of tensioning. CLINICAL RELEVANCE: Tensioning during LTT for an irreparable PSRCT may be important to sufficiently improve glenohumeral kinematics and may be an intraoperatively modifiable key variable to ensure postoperative functional success.

Clinical and biomechanical outcomes following patellar tendon repair with suture tape augmentation.

PURPOSE: Patellar tendon ruptures (PTR) occur predominantly in middle-aged patients following indirect trauma. The aim of this study was to quantify the short-term results using a suture tape augmentation technique for the repair of PTR. METHODS: All consecutive patients with acute (< 6 weeks) PTR who underwent suture tape augmentation between 03/2014 and 11/2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Visual Analog Scale (VAS) for pain, Tegner Activity Scale (TAS) and return to sport rates, Lysholm score, International Knee Documentation Committee subjective knee form (IKDC) as well as Knee Injury and Osteoarthritis Outcome Score (KOOS). Additionally, a standardized clinical examination and an isometric strength evaluation of knee extension and flexion were performed. It was hypothesized that high return to sport rates and good functional outcome would be observed and that the majority of patients would not present with a severe (> 20%) knee extension strength deficit when compared to the contralateral side. RESULTS: A total of 7 patients (mean age 37.0 ± SD 13.5 years; 6 male/1 female) were available for final assessment at a median follow-up of 17.0 (25-75% IQR 16.0-77.0) months. Three injuries occurred during ball sports, two injuries occurred during winter sports, and one injury each occurred during a motorcycling and skateboarding accident. The average time between trauma and surgery was 4.7 ± 2.6 days. At follow-up, patients reported little pain (VAS: 0 [0-0.4]). Return to sport was possible for all patients 8.9 ± 4.0 months postoperatively at a high level (TAS: 7.0 [6.0-7.0]). Five patients (71.4%) returned to the preinjury level of play, and 2 (28.6%) did not return to the preinjury level of play. Patient-reported outcome measures were moderate to good (Lysholm score: 80.4 ± 14.5; IKDC: 84.2 ± 10.6; KOOS subscales: pain 95.6 ± 6.0, symptoms 81.1 [64.9-89.1], activities of daily living 98.5 [94.1-100], sport and recreation function 82.9 ± 14.1 and knee-related quality of life 75.9 ± 16.3). All patients were very satisfied (57.1%) or satisfied (42.9%) with the postoperative result. No postoperative complications were reported. Strength measurements revealed a severe knee extension deficit in 3 patients (42.9%), but no significant deficit of isometric knee extension or flexion strength in comparison with the contralateral side was observed overall (p > 0.05). CONCLUSION: Suture tape augmentation in acute PTR repair leads to good functional outcome without major complications. Although a severe knee extension strength deficit may occur in some patients postoperatively, an excellent return to sports rate and high patient satisfaction can be expected nonetheless. LEVEL OF EVIDENCE: Retrospective cohort study; III.

Clinical Effect of Isolated Lateral Closing Wedge Distal Femoral Osteotomy Compared to Medial Opening Wedge High Tibial Osteotomy for the Correction of Varus Malalignment: A Propensity Score-Matched Analysis.

BACKGROUND: Recent evidence questions the role of medial opening wedge high tibial osteotomy (mowHTO) in the correction of femoral-based varus malalignment because of the potential creation of an oblique knee joint line. However, the clinical effectiveness of alternatively performing an isolated lateral closing wedge distal femoral osteotomy (lcwDFO), in which the mechanical unloading effect in knee flexion may be limited, is yet to be confirmed. PURPOSE/HYPOTHESIS: The purpose of this article was to compare clinical outcomes between patients undergoing varus correction via isolated lcwDFO or mowHTO, performed according to the location of the deformity, in a cohort matched for confounding variables. It was hypothesized that results from undergoing isolated lcwDFO for symptomatic varus malalignment would not significantly differ from the results after mowHTO. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Consecutive patients who underwent isolated mowHTO or lcwDFO according to a tibial- or femoral-based symptomatic varus deformity between January 2010 and October 2019 were enrolled. Confounding factors, including age at surgery, sex, body mass index, preoperative femorotibial axis, and postoperative follow-up, were matched using propensity score matching. The International Knee Documentation Committee (IKDC) Subjective Knee Form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analog scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively. RESULTS: Of 535 knees assessed for eligibility, 50 knees (n = 50 patients, n = 25 per group) were selected by propensity score matching. Compared with preoperatively, both the mowHTO group (IKDC, 55.1 ± 16.5 vs 71.3 ± 14.7, P = .002; WOMAC, 22.0 ± 18.0 vs 9.6 ± 10.8, P < .001; Lysholm, 55.2 ± 23.1 vs 80.7 ± 16, P < .001; VAS, 4.1 ± 2.4 vs 1.6 ± 1.8, P < .001) and the lcwDFO group (IKDC, 49.4 ± 14.6 vs 66 ± 20.1, P = .003; WOMAC, 25.2 ± 17.0 vs 12.9 ± 17.6, P = .003; Lysholm, 46.5 ± 15.6 vs 65.4 ± 28.7, P = .011; VAS, 4.5 ± 2.2 vs 2.6 ± 2.5, P = .001) had significantly improved at follow-up (80 ± 20 vs 81 ± 43 months). There were no significant differences between the groups at baseline, at final follow-up, or in the amount of clinical improvement in any of the outcome parameters (P > .05; respectively). CONCLUSION: Performing both mowHTO or lcwDFO yields significant improvement in clinical outcomes if performed at the location of the deformity of varus malalignment. These findings confirm the clinical effectiveness of performing an isolated lcwDFO in femoral-based varus malalignment, which is comparable with that of mowHTO in the correction of varus malalignment.

Favorable rates of return to activity and work following lateral closing wedge distal femoral osteotomy for femoral-based symptomatic varus malalignment: an analysis at a mean 6-year follow-up.

PURPOSE: To evaluate return to sport (RTS), work (RTW) and clinical outcomes following lateral closing wedge distal femoral osteotomy (LCW-DFO) for symptomatic femoral varus malalignment. METHODS: Consecutive patients who underwent LCW-DFO for symptomatic varus malalignment between 12/2007 and 03/2018 were included. The International Knee Documentation Committee (IKDC) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analogue scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively. RTS and RTW were assessed by questionnaire. RESULTS: Thirty-two patients (mean age: 45.9 ± 12.3 years), who underwent LCW-DFO for femoral-based varus malalignment (6.4 ± 3.0°), were included at a mean follow-up of 72.7 ± 39.1 months. The patient collective significantly improved in IKDC (51.8 ± 12.3 to 61.8 ± 21.5, p = 0.010; 95% CI = 3-21), WOMAC (26.7 ± 17.6 to 12.5 ± 13.5; p < 0.001; 95% CI = 21-6) and Lysholm (46.5 ± 19.4 to 67.9 ± 22.8 points (p < 0.01; 95% CI = 9-31)) scores at final follow-up. The VAS for pain reduced significantly postoperatively (4.8 ± 2.3 points to 2.6 ± 2.3 points (p = 0.002; 95% CI = 0-3)). Following LCW-DFO, 96% of patients returned to sports at a mean of 5.3 ± 2.9 months. Yet, a shift to lower impact sports compared to one year preoperatively was observed, with patients participating in a significantly lower number of high-impact disciplines (p = 0.024) and fewer hours in high-impact sports (p = 0.034). Twenty-three out of 24 patients returned to work at a mean 11.4 ± 10.9 weeks, with 18 patients reporting a similar or superior working ability. CONCLUSION: Undergoing isolated LCW-DFO for symptomatic femoral-based varus malalignment enabled the vast majority of patients to RTS and RTW along with a significant functional improvement at mid-term follow-up. However, patients' expectations have to be adequately managed regarding a limited probability to return to high-impact sports and work after surgery. LEVEL OF EVIDENCE: Retrospective case series; Level IV.

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.

Midterm outcome and strength assessment after quadriceps tendon refixation with suture anchors.

PURPOSE: Quadriceps tendon ruptures (QTR) occur predominantly in middle-aged patients through violent eccentric contraction that occurs either when trying to regain balance or during a fall on the hyperflexed knee. The aim of this study was to quantify midterm postoperative results, including strength potential measured via standardized strength tests following acute (< six weeks) quadriceps tendon refixation using suture anchors. METHODS: All consecutive patients with QTR who underwent surgical suture anchor refixation between 2012 and 2019 at a single institution with a minimum follow-up of 12 months were retrospectively evaluated. Outcome measures included Tegner Activity Scale (TAS), Lysholm score, International Knee Documentation Committee subjective knee form (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, return to work rates, and Visual Analog Scale (VAS) for pain. Additionally, a standardized clinical examination and an isometric strength assessment of knee extension and flexion were performed. RESULTS: A total of 17 patients (median age 61.0 [25-75% IQR 50.5-72.5]) were available for final assessment at a mean follow-up of 47.1 ± SD 25.4 months. The majority of patients were male (82.4%) and most injuries occurred due to a fall on the hyperflexed knee (76.5%). The average time interval between trauma and surgery was 12.7 ± 7.5 days. Patients achieved a moderate level of activity postoperatively with a median TAS of 4 (3-5.5) and reported good to excellent outcome scores (Lysholm score: 97 (86.5-100); IKDC: 80.7 ± 13.5; KOOS subscales: pain 97.2 (93.1-100), symptoms 92.9 (82.5-100), activities of daily living 97.1 (93.4-100), sport and recreation function 80 (40-97.5) and knee-related quality of life 87.5 (62.5-100). All patients were able to fully return to work and reported little pain [VAS: 0 (0-0)]. No postoperative complications were reported. Strength measurements revealed a significant deficit of knee extension strength in comparison to the contralateral side (p = 0.011). CONCLUSION: Suture anchor refixation of acute QTR leads to good functional results and high patient satisfaction without major complications. Isometric knee extension strength, however, may not be fully restored compared to the unaffected side.

Low postoperative complication rate with high survival rate and good clinical outcome 9 years after autologous chondrocyte transplantation of the knee joint.

PURPOSE: To investigate postoperative complications and associated risk factors for failure following autologous chondrocyte transplantation ("ACT") as well as its long-term survival and clinical function. It was hypothesized that ACT is a safe technique for cartilage repair with a low incidence of postoperative complications and rare rates of revision surgery combined with a high long-term survival and good to excellent clinical outcome in long-term-follow-up. METHODS: All patients undergoing ACT-Cs of the knee joint between 2006 and 2012 at the author's institution were included in this retrospective study. Concomitant procedures had been performed if necessary. Early postoperative complications, revision surgeries, failure and risk factors for those events were evaluated 6 months after the surgery. Long-term clinical outcome was assessed using the Lysholm Score, the Tegner Score, a 10-grade scale for satisfaction and the Visual Analogue Scale (VAS) at a minimum follow-up of 9 years postoperatively. Long-term survival was calculated using revision surgeries, clinical failures and conversion procedures to create a Kaplan-Meier analysis. A subgroup analysis for different defect locations was performed. 139 patients were included in this study (27% female/ 73%male; age 26.7 [21.7; 35.2] years). The median defect size was 4.0 [3.0; 6.0] cm2 (40% medial femoral condyle (MFC), 17% lateral femoral condyle (LFC), 36% patella, 19% trochlea). 97 (70%) of the patients had undergone previous surgery and 84 (60%) underwent concomitant procedures. RESULTS: Postoperatively, 8% of patients had complications (4% bleeding, 2% arthrofibrosis, 2% infection), 7% of patients needed revision surgery. 12% of patients had a prolonged deficit in ROM, that did not require revision surgery. No significant difference in terms of complications was found between the patellofemoral and femorotibial group. Patients demonstrated good patient reported long-term outcomes 9-15 years after the index surgery (Tegner: 4.7 ± 1.8; VAS: 2.4 ± 2.1; Lysholm: 80 ± 14; satisfaction with operation: 7.3 ± 1.9). Survival rates were 88% at 9 years, 85% at 11 years, and 85% at 13 years after the index procedure. Reasons for failure included debridement of ACT (n = 4; 5%), revision ACT (n = 3, 3%), conversion to total knee arthroplasty (n = 3, 3%) and conversion to High tibial osteotomy (HTO) (n = 1; 1%)). CONCLUSION: The present study indicates ACT as an effective treatment option for femorotibial- as well as patellofemoral cartilage defects with a high long-term survival and low conversion rate as well as good long-term results regarding knee function and satisfaction. Postoperative complications needing revision surgery are rare. Prolongated deficits of range of motion appear frequently up to six months especially in patellofemoral defects, but can often be successfully addressed by intensified physiotherapy without requiring an arthrolysis. LEVEL OF EVIDENCE: Level III.

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.

Empfehlungen der AG Klinische Geweberegeneration zur Behandlung von Knorpelschäden am Kniegelenk. / Empfehlungen der AG Klinische Geweberegeneration zur Behandlung von Knorpelschäden am Kniegelenk.

The Working Group of the German Orthopedic and Trauma Society (DGOU) on Tissue Regeneration has published recommendations on the indication of different surgical approaches for treatment of full-thickness cartilage defects in the knee joint in 2004, 2013 and 2016. Based upon new scientific knowledge and new developments, this recommendation is an update based upon the best clinical evidence available. In addition to prospective randomised controlled clinical trials, this also includes studies with a lower level of evidence. In the absence of evidence, the decision is based on a consensus process within the members of the working group.The principle of making decision dependent on defect size has not been changed in the new recommendation either. The indication for arthroscopic microfracturing has been reduced up to a defect size of 2 cm2 maximum, while autologous chondrocyte implantation is the method of choice for larger cartilage defects. Additionally, matrix-augmented bone marrow stimulation (mBMS) has been included in the recommendation for defects ranging from 1 to 4.5 cm2. For the treatment of smaller osteochondral defects, in addition to osteochondral transplantation (OCT), mBMS is also recommended. For larger defects, matrix-augmented autologous chondrocyte implantation (mACI/mACT) in combination with augmentation of the subchondral bone is recommended.

Editorial Commentary: Double-Sling Transfer of Both the Conjoined Tendons and Long Head Biceps Tendon for Glenoid Bone Loss in Patients With Shoulder Instability Shows Biomechanical Benefit in Shoulder Abduction and External Rotation But May Be Insufficient in Mid-Range Arm Positions.

Recurrence of shoulder glenohumeral instability is exacerbated in cases of glenoid bone loss. Surgical bone transfer techniques well address the issue. Innovative soft-tissue tendon transfers may fill the defect plus provide a sling effect. Double-sling transfer of both the conjoined tendons and long head biceps tendon for glenoid bone loss in patients with shoulder instability shows biomechanical benefit in shoulder abduction and external rotation. However, as the sling effect is less pronounced in mid-range arm position, the benefit of double-sling transfer may be insufficient. Moreover, the biomechanical models are limited relative to the complexity of clinical glenohumeral function, and obviously limited to time-zero analysis. We should be careful before we abandon bony augmentation procedures.

Excellent clinical and radiological outcomes after both open flake refixation and autologous chondrocyte implantation following acute patella dislocation and concomitant flake fractures.

PURPOSE: To investigate clinical and magnetic resonance (MR) imaging results of patients undergoing patella stabilization with either open flake refixation (oFR) or autologous chondrocyte implantation (ACI) and concomitant soft tissue patella stabilization after sustaining primary, acute patella dislocation with confirmed chondral and/or osteochondral flake fractures. It was hypothesized that refixation will lead to better results than ACI at mid-term follow-up. METHODS: A retrospective chart review was conducted to identify all patients undergoing oFR or ACI after sustaining (osteo-)chondral flake fractures and concomitant soft tissue patella stabilization following primary, acute patella dislocation between 01/2012 and 09/2018 at the author's institution. Patients were excluded if they were aged < 14 years or > 30 and had previous knee surgeries at the index knee. Clinical outcomes were assessed using the Tegner activity score, Kujala score, subjective IKDC score, and the KOOS score at a minimum follow-up of 24 months postoperatively. MR images were assessed using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 knee score. Thirty patients were included in the study, with 16 patients assorted to the oFR group and 14 patients to the ACI group (Follow-up 81%). RESULTS: Demographic data did not show significant group differences (oFR: 6 females, 10 males; age 26.9 ± 5.6 years, FU: 57 months (27-97 months); ACI: 9 females, 5 males; age 25.5 ± 4.9 years, FU: 51 months (29-91 months); n.s.). Defect location was similar in both groups (oFR: 12 × patella/4 × lateral femoral condyle; ACI: 12/2; n.s.). Both groups showed excellent clinical outcomes, with no statistically significant difference between both the groups (oFR group vs. ACI group: Tegner: 5.1 ± 1.8 vs. 5.1 ± 1.4; Kujala: 86.1 ± 12.6 vs. 84.9 ± 9.1; IKDC: 83.8 ± 15.0 vs. 83.6 ± 11.3; KOOS: 83.3 ± 14.0 vs. 83.6 ± 12.0; n.s.). One patient in each group suffered a patella re-dislocation and needed revision surgery. The MOCART 2.0 score showed good results for the oFR group (68.2 ± 11.1) and the ACI group (61.1 ± 16.9) while no significant differences were noted between both the groups. The inter-rater reliability was excellent (0.847). CONCLUSION: Open refixation of (osteo-)chondral fragments in patients after sustaining acute patella dislocation with (osteo)-chondral flake fractures led to good clinical and radiological results at a minimum follow of 24 months, showing that it is a good surgical option in the treatment algorithm. However, if open refixation is not possible, ACI may be an excellent fallback option in these younger patients with equally good clinical and radiological outcomes, but requiring a second minimally invasive surgery. LEVEL OF EVIDENCE: III.

Autologous chondrocyte implantation combined with anterior cruciate ligament reconstruction: similar short-term results in comparison with isolated cartilage repair in ligament intact joints.

PURPOSE: Both acute ruptures of the anterior cruciate ligament (ACL) as well as chronic ACL insufficiency show a high association with focal cartilage defects of the knee. However, the results after combined ACL reconstruction and cartilage repair are not well investigated. The aim of the present study was to investigate the short-term outcomes after autologous chondrocyte implantation (ACI) in combination with ACL reconstruction and to compare the results with patients who underwent isolated ACI in ligament intact knees. METHODS: All patients who were registered in the German Cartilage Registry with ACI for focal cartilage defects in the knee joint in combination with ACL reconstruction and who completed the 24 month follow-up were included in the study group. A matched-pair procedure according to gender, defect location, defect size, and age was used to create a control group of patients with isolated ACI in ACL intact joints. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the numeric analog scale for pain (NAS) were used to assess the preoperative state as well as the clinical outcomes 12 and 24 months after surgery. RESULTS: A total of 34 patients were included in both the study group (age mean 33.3 ± SD 8.8 years) and the control group (33.6 ± 8.4 years) with a median defect size of 466 (25%-75% IQR 375-600) mm2 and 425 (IQR 375-600) mm2, respectively. In comparison with the preoperative state (median 67, IQR 52-75), the study group showed a significant increase of the total KOOS after 12 months (78, IQR 70-86; p = 0.014) and after 24 months (81, IQR 70-84; p = 0.001). The NAS for pain did not change significantly in the postoperative course. In comparison with the control group there was no significant difference for the total KOOS neither preoperative (control group median 67, IQR 52-73) nor at any postoperative time point (12 months: 82, IQR 67-93; 24 months: 81, IQR 71-91). CONCLUSION: The clinical short-term outcomes after ACI at the knee joint in combination with ACL reconstruction are good and similar to the results after isolated ACI in ligament intact knees. LEVEL OF EVIDENCE: III.