Return to Play and Pattern of Injury After ACL Rupture in a Consecutive Series of Elite UEFA Soccer Players.

Background: Anterior cruciate ligament rupture represents a career-threatening injury for professional soccer players. Purpose: To analyze the pattern of injury, return to play (RTP), and performance of a consecutive series of elite professional soccer players after anterior cruciate ligament reconstruction (ACLR). Study Design: Case series; Level of evidence, 4. Methods: We evaluated the medical records of 40 consecutive elite soccer players who underwent ACLR by a single surgeon between September 2018 and May 2022. Patient age, height, weight, body mass index, position, injury history, affected side, RTP time, minutes played per season (MPS), and MPS as a percentage of playable minutes before and after ACLR were retrieved from medical records and from publicly available media-based platforms. Results: Included were 27 male patients (mean ± SD age at surgery, 23.2 ± 4.3 years; range, 18-34 years). The injury occurred during matches in 24 players (88.9%), with a noncontact mechanism in 22 (91.7%). Meniscal pathology was found in 21 patients (77.8%). Lateral meniscectomy and meniscal repair were performed in 2 (7.4%) and 14 (51.9%) patients, respectively, and medial meniscectomy and meniscal repair were performed in 3 (11.1%) and 13 (48.1%) patients, respectively. A total of 17 players (63.0%) underwent ACLR with bone-patellar tendon-bone autograft and 10 (37.0%) with soft tissue quadriceps tendon. Lateral extra-articular tenodesis was added in 5 patients (18.5%). The overall RTP rate was 92.6% (25 of 27). Two athletes moved to a lower league after surgery. The mean MPS% during the last preinjury season was 56.69% ± 21.71%; this decreased significantly to 29.18% ± 20.6% (P < .001) in the first postoperative season and then increased to 57.76% ± 22.89% and 55.89% ± 25.8% in the second and third postoperative seasons. Two (7.4%) reruptures and 2 (7.4%) failed meniscal repairs were reported. Conclusion: ACLR in elite UEFA soccer players was associated with a 92.6% rate of RTP and 7.4% rate of reinjury within 6 months after primary surgery. Moreover, 7.4% of soccer players moved to a lower league during the first season after surgery. Age, graft selection, concomitant treatments, and lateral extra-articular tenodesis were not significantly associated with prolonged RTP.

Video analysis of Achilles tendon ruptures in professional male football (soccer) reveals underlying injury patterns and provides strategies for injury prevention.

PURPOSE: In professional football (soccer), Achilles tendon ruptures are severe injuries. Video analysis promotes a better understanding of the underlying situational and biomechanical patterns, and provides a roadmap for future research to improve the management and prevention of Achilles tendon ruptures. The purpose of this study was to identify injury patterns contributing to acute Achilles tendon ruptures in professional male football players. METHODS: Professional male football players with an acute Achilles tendon rupture were identified using an online database. For every in-competition injury, the corresponding football match was detected. Video footage of the injury was accessed using Wyscout.com or publicly available video databases. Situational patterns and injury biomechanics of the injury frame were independently analysed by two reviewers using a standardised checklist and a motion analysis software. Finally, consensus was reached to describe the main injury patterns of Achilles tendon ruptures in professional male football players. RESULTS: The search identified video footage of 80 Achilles tendon ruptures in 78 players. Most injuries (94%) occurred through indirect or non-contact mechanisms. The kinematic analysis revealed characteristic joint positions at the time of injury consisting of hip extension, knee extension, ankle dorsiflexion, foot abduction, and foot pronation in most cases. The underlying direction of movement was from flexion to extension (knee) and from plantarflexion to dorsiflexion (ankle). Player actions identified as main injury patterns were stepping back (26%), landing (20%), running/sprinting (18%), jumping (13%), and starting (10%). CONCLUSION: Most Achilles tendon ruptures in professional male football players are closed-chain indirect or non-contact injuries. Sudden loading to the plantarflexor musculotendinous unit remains to be the main component for most cases. By achieving a better understanding of underlying injury mechanisms, this study provides new strategies for the prevention of Achilles tendon ruptures. LEVEL OF EVIDENCE: Level IV.

Bilateral Looser zones or pseudofractures in the anteromedial tibia as a component of medial tibial stress syndrome in athletes.

PURPOSE: Medial tibial stress syndrome (MTSS) represents a common diagnosis in individuals exposed to repetitive high-stress loads affecting the lower limb, e.g., high-performance athletes. However, the diagnostic approach and therapeutic regimens are not well established. METHODS: Nine patients, diagnosed as MTSS, were analyzed by a comprehensive skeletal analysis including laboratory bone turnover parameters, dual-energy X-Ray absorptiometry (DXA), and high-resolution peripheral quantitative computed tomography (HR-pQCT). RESULTS: In 4/9 patients, bilateral pseudofractures were detected in the mid-shaft tibia. These patients had significantly lower levels of 25-hydroxycholecalciferol compared to patients with MTSS but similar levels of bone turnover parameters. Interestingly, the skeletal assessment revealed significantly higher bone mineral density (BMD) Z-scores at the hip (1.3 ± 0.6 vs. - 0.7 ± 0.5, p = 0.013) in patients with pseudofractures and a trend towards higher bone microarchitecture parameters measured by HR-pQCT at the distal tibia. Vitamin D supplementation restored the calcium-homeostasis in all patients. Combined with weight-bearing as tolerated, pseudofractures healed in all patients and return to competition was achieved. CONCLUSION: In conclusion, deficient vitamin D levels may lead to pseudofractures due to localized deterioration of mineralization, representing a pivotal component of MTSS in athletes with increased repetitive mechanical loading of the lower limbs. Moreover, the manifestation of pseudofractures is not a consequence of an altered BMD nor microarchitecture but appears in patients with exercise-induced BMD increase in combination with reduced 25-OH-D levels. The screening of MTSS patients for pseudofractures is crucial for the initiation of an appropriate treatment such as vitamin D supplementation to prevent a prolonged course of healing or recurrence. LEVEL OF EVIDENCE: III.

[Impact of Vitamin D in Sports: Does Vitamin D Insufficiency Compromise Athletic Performance?] / Bedeutung von Vitamin D im Sport: Reduziert ein Mangel die Leistungsfähigkeit?

Introduction Vitamin D is essential for calcium homeostasis and regulates the expression of over 900 genes. It thereby influences musculoskeletal health and function. Additionally, multiple other effects were observed through the detection of vitamin D receptors (VDR) in numerous tissues of the human body. Material and Methods We reviewed the literature regarding evidence of the impact of vitamin D on musculoskeletal health and peak athletic performance. Results and Discussion It is well known that there is a high prevalence of vitamin D deficiency in the average European population. This article confirmed the same for athletes in different disciplines. Therefore, vitamin D deficiency and its effects are relevant for competitive sports. The surprisingly high prevalence of inadequate vitamin D levels depends on the geographic location, the time of day and year, local climate conditions, and sports disciplines (indoor vs. outdoor). Based on the analysed literature, we found several correlations between 25-OH-D3 serum levels and different aspects of competitive sports. A serum level ≥ 30 ng/ml provides sufficient mineralisation of non-mineralised bone matrix and is therefore crucial for skeletal health. Furthermore, this concentration was positively correlated with an accelerated regeneration of muscular force. Levels above 40 ng/ml provided a protective effect on the development of stress fractures. Researchers suspect that levels above 50 ng/ml are required for athletes to achieve maximal physical performance. While there is an ongoing discussion amongst researchers regarding beneficial effects of such high levels, it is well known that blood levels lower than 30 ng/ml lead to mineralisation defects in bone (rickets, osteomalacia) and muscular function (reversible myopathy). Conclusion This review suggests that athletes should have an evaluation of vitamin D-dependent calcium homeostasis based on laboratory tests of 25-OH-D3, calcium, creatinine, and parathyroid hormone. In case of vitamin D insufficiency, normal blood levels of ≥ 30 ng/ml may be restored by optimising the athlete's lifestyle and, if appropriate, oral substitution of cholecalciferol. This concentration is associated with a protective effect and enhancement of physical performance. Consequently, it is a requirement for restoring and maintaining musculoskeletal health and athletic performance.

Intra-articular osteoid osteoma as a differential diagnosis of diffuse mono-articular joint pain.

BACKGROUND: The aim of this retrospective study was to investigate the frequency of intra-articular osteoid osteoma (iaOO) in a large study cohort and to demonstrate its clinical relevance as an important differential diagnosis of non-specific mono-articular joint pain. METHODS: We searched the registry for bone tumours of the University Medical Centre Hamburg-Eppendorf for osteoid osteomas in the last 42 years. Herein, we present three selected iaOO which were detected in the three major weight-bearing joints. Computed tomography (CT) or magnetic resonance imaging (MRI) scans were performed for initial diagnosis. RESULTS: Out of a total of 367 osteoid osteomas, 19 (5.2 %) tumours were localized intra-articularly. In all three presented tumours, a history of severe mono-articular pain was reported; however, the mean time to correct diagnosis was delayed to 20.7 months. Clearly, the nidus seen in CT and MRI images in combination with inconsistent salicylate-responsive nocturnal pain led to the diagnosis of iaOO. CONCLUSIONS: Rarely, osteoid osteoma can occur in an intra-articular location. In cases of diffuse mono-articular pain, iaOO should be considered both in large and smaller joints to avoid delays in diagnosis and therapy of this benign bone tumour.

Nonoperative treatment and return to play after complete proximal adductor avulsion in high-performance athletes.

PURPOSE: To assess the outcome of nonoperative treatment after complete avulsion of the proximal adductor longus tendon in high-performance athletes. METHODS: Six consecutive athletes were included. Treatment was conservative following a strict rehabilitation plan. Following parameters were analysed: basic data, mechanism of injury, classification, tendon retraction, size of defect in MRI and return to play (RTP). RESULTS: Mean age at injury was 28 ± 5 (range 20-32) years. Overstretch (83 %) and kicking (50 %) were the most frequent injury mechanisms, and the dominant leg was involved in 83 %. Average retraction of the avulsed tendon amounted 21 ± 5 mm. Follow-up MRIs demonstrated a gradual reattachment of the tendon in all cases. All athletes returned to full sportive activity on preinjury level within 88.7 ± 12.8 (range 75-110) days with no functional deficiencies. Manual muscle strength was equal to the contralateral side. CONCLUSION: Nonoperative treatment with a healing phase and a strict rehabilitation plan results in a functional, efficient reattachment of the tendon and allows unrestricted RTP. Since these injuries are rare, present study may help sports physicians when dealing with this type of injuries in professional athletes. Return to sports can be expected at approximately 13 weeks after injury, but can take even longer. LEVEL OF EVIDENCE: Case series, Level IV.

Suture anchor repair of proximal rectus femoris avulsions in elite football players.

PURPOSE: To report the results of suture anchor repair of proximal rectus femoris avulsions in elite football players. METHODS: Four professional football players (first-team regulars of European first division football clubs) underwent suture anchor repair of complete proximal rectus femoris avulsions with significant tendon retraction. The following parameters were analysed: demographic data, mechanism of injury, type of injury, classification according to the Munich consensus statement, time between injury and surgery, time between surgery and full participation in training and availability for match and/or competition selection (return to play/RTP), and time between surgery and the comeback to the first official league match (return to competition/RTC). Radiographic evaluation was performed by magnetic resonance imaging (MRI) obtained pre-operatively and at 6 and 12 weeks post-operatively. All players were followed for at least 24 months after return to play to exclude recurrence. RESULTS: Mean age at surgery was 30 ± 2 years. All injuries occurred while kicking a ball, with the dominant leg affected in all patients. The injury was considered acute in three cases and chronic in one case. According to the Munich classification, all injures were type 4. Mean time to surgery was 60 ± 88 days (range, 8-191), mean time to RTP was 111 ± 15 days (range, 100-134), and mean time to RTC was 140 ± 23 days (range, 114-166). Follow-up MRIs demonstrated anatomically reinserted tendons with decreasing signal intensity over time in all cases. After a mean follow-up of 35 ± 6 months, all players were still competing at the same level as before the injury without re-injury. CONCLUSION: Suture anchor repair of proximal rectus femoris avulsions allows unrestricted return to play in professional elite football players. Return to play can be expected at approximately 16 weeks post-operatively.

Intravenous bisphosphonates and vitamin D in the treatment of bone marrow oedema in professional athletes.

INTRODUCTION: The goal of this retrospective study was to evaluate the safety and efficacy of ibandronate for bone marrow oedema (BMO) syndrome and stress fracture cases, and to demonstrate an additional field of therapeutic importance-the high-performance athlete. PATIENTS AND METHODS: This retrospective study included twenty-five high-performance athletes. Sixty per cent of the athletes were European soccer players and 40.0% other high-class international athletes (3 women and 22 men with an average age of 25.0±4.2), with BMO of the lower trunk or extremity diagnosed by magnetic resonance imaging (MRI). The treatment regimen consisted of high-dose vitamin D supplementation and intravenous ibandronate therapy. RESULTS: The time between the onset of pain and proper diagnosis of BMO was 106.3±104.1 days. Excellent pain reduction (pain at rest and under strain) and improved mobility was reported within the first two weeks after the first ibandronate administration by sixteen patients (64%). The time from first treatment until return to competition (RTC) was on average 102.6±65.2 days in total. If the time from onset of pain until diagnosis was within 40 days, the RTC was significantly reduced (p≤0.05) to almost 50% (63.8±48.1 days) when compared to the athletes with later diagnosis (124.4±63.2 days). CONCLUSIONS: The here-applied therapy regimen of intravenous BPs application and vitamin D supplementation in BMO syndrome has a beneficial effect for high-performance athletes. An early diagnosis and rapid treatment start can reduce the RTC significantly. An optimal bone metabolism with sufficient daily calcium and vitamin D intake is crucial and should not only be strived for the professional but also for the recreational athlete.

Efficient and stable gene transfer of growth factors into chondrogenic cells and primary articular chondrocytes using a VSV.G pseudotyped retroviral vector.

Since efficient transfer of foreign genes into primary articular chondrocytes (CC) is difficult, a VSV.G pseudotyped retroviral vector (Bullet) was developed for marker and growth factor gene transfer. Transduction efficiency was analysed by FACS. BMP2 production was determined by specific hBMP2-ELISA. BMP2 effect on cells regarding proteoglycan production was measured by alcian blue staining and dye quantification. Alkaline phosphatase activity was determined by enzymatic reaction with p-nitrophenyl phosphate at OD 405nm and proliferation rate was analysed by MTT-assay. ATDC5 cells (98.3+/-0.6%SD) were transduced to express the reporter gene eGFP. After 52 weeks 94.7+/-0.6%SD of cells were positive. Retroviral transduction efficiency for nlslacZ exceeded 92.3+/-6.1%SD in rabbit CC and expression remained high after 15 weeks (75.7+/-14.2%SD). ATDC5 cells and CC expressed the growth factor gene hBMP2 after retroviral transduction at different time-points. BMP2 led to an increase in proteoglycan and alkaline phosphatase production. Initially, the proliferation rate detected by MTT-assay increased in both the cell types; afterwards the proliferation rate was similar to controls. The described retroviral vector system achieved high initial transduction rates in ATDC5 cells and CC. Gene transfer was very stable over the time period analysed, rendering it a useful tool for future in vitro and in vivo studies on cartilage remodelling.

The fate of osteochondral grafts after autologous osteochondral transplantation: a one-year follow-up study in a minipig model.

INTRODUCTION: Because articular cartilage shows little intrinsic capacity of spontaneous regeneration, a variety of treatment options are currently at use to repair cartilage damage. One of these is the autologous osteochondral transplantation (AOT). The aim of the present work was to study the histological changes during the progress of 1 year after AOT in the knee joint. MATERIALS AND METHODS: Twelve Minipigs underwent an AOT on the medial femoral condyles of both knees using cooled diamond studded trephines with a diameter of the grafts of 4.6 mm. Three animals were sacrificed at each 2, 8, 26 and 52 weeks after the operation. The condyles were analyzed histologically and immunohistologically for collagen types I and II. RESULTS: A successful bony incorporation was observed in all specimens. The transplant demonstrated an increasingly stable integration of the chondral matrix into the cartilage of the surrounding femoral condyle. At 52 weeks after the operations 5 of 6 condyles showed a chondral integration at least at one side of the graft. Immunohistologically all specimens showed physiological staining characteristics up to 52 weeks after operation. The quality of the chondral part of the graft showed a wide range of variations, ranging from vital tissue resembling native cartilage after 52 weeks, to severe degenerative signs beginning 2 weeks after operation and ending at 52 weeks with deep fissures fragmenting the cartilage and the complete loss of vital cells. CONCLUSION: The press-fit technique allows a stable bony incorporation. A chondral integration of the graft seems to occur, provided that a close contact between the interfaces can be achieved. Present results demonstrate a vital cartilagenous transplant for up to 52 weeks. However, some specimens showed in part severe degenerative signs. A possible explanation is an insufficient cooling of the trephines in relation to the small diameter of the grafts used in the minipig model. The collagen network seems not to be affected for up to 52 weeks.

Osteochondral transplantation to treat osteochondral lesions in the elbow.

BACKGROUND: Effective treatment of osteochondral lesions in the elbow remains challenging. Arthroscopic débridement and microfracture or retrograde drilling techniques are often insufficient and provide only temporary symptomatic relief. The purpose of this study was to evaluate the treatment of these lesions with osteochondral autografts. METHODS: From 1999 to 2002, seven patients with osteochondral lesions of the capitellum humeri (five patients), trochlea (one patient), or radial head (one patient) were treated with cylindrical osteochondral grafts, which were harvested from the non-weight-bearing area of the proximal aspect of the lateral femoral condyle. The patients (three female and four male patients with an average age of seventeen years) were evaluated preoperatively and postoperatively, with an average follow-up of fifty-nine months. The Broberg and Morrey score was chosen for functional evaluation of the elbow (with regard to motion, pain, strength, activities of daily living, and stability), and the American Shoulder and Elbow Surgeons score was used for the analysis of pain. All patients had imaging studies done preoperatively to evaluate the defect and postoperatively to assess the ingrowth and viability of the graft. The ipsilateral knee was examined for donor-site morbidity. RESULTS: The Broberg and Morrey score improved from a mean (and standard deviation) of 76.3 +/- 13.2 preoperatively to 97.6 +/- 2.7 postoperatively, and pain scores were significantly reduced (p < 0.05). The mean elbow extension lag of 4.7 degrees +/- 5.8 degrees was reduced to 0 degrees postoperatively. Compared with the contralateral side, there was a mean preoperative flexion lag of 12.9 degrees +/- 13.8 degrees . At the time of the final follow-up, flexion was free and was equal bilaterally in all patients. None of the plain radiographs made at the time of follow-up showed any degenerative changes or signs of osteoarthritis. The postoperative magnetic resonance imaging scans showed graft viability and a congruent chondral surface in all seven patients. No donor-site morbidity was noted at one year postoperatively. CONCLUSIONS: The osteochondral autograft procedure described in the present study provides the opportunity to retain viable hyaline cartilage for the repair of osteochondral lesions in the elbow while restoring joint congruity and function and perhaps reducing the risk of osteoarthritis. These medium-term results suggest that the risks of a two-joint procedure are modest and justifiable. In addition, the described technique provides an option for revision surgery after the failure of other surgical procedures.

In vivo analysis of retroviral gene transfer to chondrocytes within collagen scaffolds for the treatment of osteochondral defects.

To examine a retroviral gene transfer to chondrocytes in vitro and in vivo in tissue-engineered cell-collagen constructs articular chondrocytes from rabbits and humans were isolated and transduced with VSV.G pseudotyped murine leukemia virus-derived retroviral vectors. Viral supernatants were generated by transient transfection of 293T cells using the pBullet retroviral vector carrying the nlslacZ gene, a Moloney murine leukemia virus gag/pol plasmid and a VSV.G coding plasmid. Transduction efficiency was analyzed by fluorescence-activated-cell-sorter analysis and transduced autologous chondrocytes from rabbits were seeded on collagen-scaffolds and implanted into osteochondral defects in the patellar groove of the rabbit's femur (n=10). LacZ-expression was analyzed by X-gal staining on total knee explants and histological sections. Retroviral transduction efficiency exceeded 92.3% (SEM+/-3.5%) in rabbit articular chondrocytes, 74.7% (SEM+/-1.8%) in human articular chondrocytes and 52.7% (SEM+/-5.8%) in osteoarthritic human chondrocytes. Reporter gene expression remained high after 15 weeks in 75.7% (SEM+/-8.2%) of transduced rabbit articular chondrocytes. In vivo, intraarticular beta-galactosidase activity could be determined in the majority of implanted chondrocytes in the osteochondral defects after 4 weeks.

Antegrade nailing of humeral head fractures with captured interlocking screws.

OBJECTIVES/DESIGN: To assess the functional outcome after treatment of proximal humeral fractures with a new antegrade nail that provides angular and sliding stability. INTERVENTION/PATIENTS: Ninety-seven patients were treated during a 4-year period between April 2000 and March 2004. All patients were followed for 6 months, 51 patients (53%) for 12 months, and 31 patients (32%) for 24 months. This study focuses mainly on the patients with a follow up of 1 year. Their mean age was 68 years (range: 33 to 90); 22% were more than 80 years of age. MAIN OUTCOME MEASUREMENTS: All fractures were radiologically graded by the Neer and AO/ASIF classifications. Clinical assessment was performed at all follow-up visits using the Constant-Murley and Neer scores, and complications were recorded. RESULTS: There were 26.8% 2-part, 66% 3-part, and 7.2% 4-part fractures. The relative Constant-Murley score improved significantly (P < 0.001) from 72% at 6 months to 82% at 12 months after operation. No further improvement regarding functional outcome was observed after 24 months. Patients younger than 60 years of age had better results. No significant functional differences were found among 2-, 3- or 4-part fractures. Complications included backing out of the proximal screws (9.8%), secondary dislocation (1.9%), complete osteonecrosis (1.9%), and partial osteonecrosis (5.8%). CONCLUSION: Treatment with this nail provides sufficient fixation of the fragments to allow early mobilization. The good functional results in the majority of the patients indicate that this nail can be used, even in complex fractures and elderly patients.

Mechanical evaluation of different techniques for Achilles tendon repair.

INTRODUCTION: One aim of the surgical treatment of acute Achilles tendon ruptures is to obtain a maximum primary stability of the sutured tendon. Therefore, we investigated the primary stability of sutured human Achilles tendons depending on different applied techniques. METHODS: The strength of 60 repaired cadaveric human Achilles tendons was tested depending on either the suture technique (Bunnell or Kessler), the suture material (PDS-thread or PDS-cord) or an additional plantaris tendon augmentation (PDS-thread with or without augmentation). Following anatomic reconstruction the repaired specimens were loaded to failure. RESULTS: The use of Bunnell's technique resulted in a stronger primary suture stability compared to Kessler's technique. Sutures carried out with a PDS-thread were of lower strength than those accomplished with a PDS-cord (Bunnell: thread 139 N +/- 29.8; cord 291 N +/- 55.2/Kessler: thread 137 N +/- 37.3; cord 180 N +/- 41.1). Sutures performed according to Bunnell's technique with a PDS-thread and an additional autologous plantaris tendon augmentation reached the highest primary stability (326 N +/- 124.9). CONCLUSIONS: The findings identify the Achilles tendon suture with a PDS-cord according to Bunnell's technique as a mechanically strong method. A plantaris tendon augmentation in addition to a PDS-thread can even add more stability to the Achilles tendon suture.

Arthroscopical Findings after Antegrade Nailing of a Proximal Humeral Fracture : Case Report and Review of the Literature.

Proximal humeral fractures represent up to five percent of all fractures in adults, commonly found in elderly patients. The final functional results after different operative procedures are among other factors dependent on whether or not a rotator cuff lesion is pre-existent, prior to the fracture, and how its surgical therapy is carried out. However, to what extent prior rotator cuff tears in this special patient group contribute to the functional outcome remains widely unclear. In our institution antegrade intramedullary nailing is the treatment of choice for proximal humeral fractures. One critical point of this technique is the unavoidable split of the rotator cuff on the approach to the proximal humerus and the insertion of the nail through the incised cuff. We report on a case of an impingement after antegrade intramedullary nailing of a proximal humeral fracture. Diagnostic glenohumeral arthroscopy revealed neither a residual lesion of the former rotator cuff incision nor a chondral lesion at the former insertion site of the nail. In the same session subacromial decompression and a nettoyage of adhesions were performed. We assume that splitting the rotator cuff for the insertion of an antegrade nail in a proximal humeral fracture is less relevant than previously assumed and described.

Retrograde cartilage transplantation on the proximal and distal tibia.

The authors, with experience with more than 400 osteochondral autograft transplantation (OATS) cases since 1996, report a new technique of a retrograde osteochondral autograft transplantation for the treatment of isolated osteochondral lesions of the proximal and the distal tibia started in 1999. We treated 5 patients, 3 who presented with painful traumatic chondral defects in the central weight-bearing portion of the tibial plateau (1 in the medial and 2 in the lateral compartment), and 2 who presented with painful chondral lesions on the distal tibia. An anterior cruciate ligament (ACL) drill guide positioned in the center of the defect was used to accurately prepare the cartilage surface, in one case arthroscopically and in 4 cases through an open incision. A guide-wire was introduced and drilled through the tibia, and a cannulated reamer equal to the diameter of the defect was advanced. An osteochondral cylinder was harvested from the non-weight-bearing zone of the femoral trochlea at the angle that corresponded to the angle on the ACL drill guide. The autograft was inserted in a retrograde fashion from the cortical window into the tibial tunnel to be flush with the articular surface in press-fit technique. The remaining tunnel defect between the cortical window on the tibia and the distal aspect of the autograft was filled with a cancellous bony cylinder and secured with a diagonal bioabsorbable screw. A concomitant varus deformity with the lesion on the medial tibial plateau was corrected in the same surgery using a high tibial osteotomy to relieve stress on the graft. Patients were followed up for 6 to 35 months. A complete healing of the grafts was seen in control magnetic resonance images (MRIs). All patients were satisfied with the surgery. Control arthroscopies showed the osteochondral cylinders well integrated and flush with the articular surface.