Trochlear Dysplasia Is Associated With Increased Sagittal Tibial Tubercle Trochlear-Groove Distance in Patients With Patellar Instability.

PURPOSE: To compare the sagittal position of the tibial tubercle in relation the trochlea groove in patients with and without trochlear dysplasia (TD). Patients with high-grade TD show a significantly increased sagittal position of the tibial tubercle in relation to the trochlear groove (sTTTG) compared with patients without TD. This may affect patellofemoral loading and contribute to the increased prevalence of cartilage lesions seen in the patellofemoral joint of patients with dysplasia of the trochlear groove. METHODS: All patients between January 2017 and December 2020 with high-grade TD (Dejour type B, C, and D) who underwent patellar-stabilizing surgery for patellar instability at a single institution were included in the current study. Patients without preoperative magnetic resonance imaging (MRI), any previous osteotomy on the affected lower extremity, or cruciate ligament insufficiency were excluded. Patients who underwent knee arthroscopy for meniscal repair/debridement without any signs of TD or any of the aforementioned criteria served as the control group. Preoperative MRI was retrospectively assessed to compare common patellofemoral anatomic parameters including patellar angle, patellar tilt, patella morphology according to Wiberg, Caton-Deschamps index, PF index, trochlear sulcus angle, sulcus depth, lateral inclination angle of the trochlea, tibiofemoral rotation, TTTG, and sTTTG distance between both groups. The sTTTG is measured as the distance between the nadir point of the cartilaginous trochlear groove and the most anterior point of the tibial tubercle on an axial MRI. Independent predictors for the sTTTG were assessed for patients with TD. RESULTS: Patients with high-grade TD (n = 82) showed an increased patellar tilt, Caton-Deschamps index, trochlear sulcus angle, lateral tibiofemoral rotation angle, TTTG, and sTTTG (9.16 ± 4.47 mm vs 2.66 ± 4.21 mm) compared with the control group (n = 83) (P < .001). Patellar angle, PF index, sulcus depth, and lateral inclination angle of the trochlear were significantly decreased in the TD group (P < .001). The sTTTG was similar in all TD groups (n.s.). Among patients with TD, both tibiofemoral rotation and patellar height were independent predictors of the sTTTG (P < .05). CONCLUSIONS: Patients with high-grade TD show not only abnormal values in common patellofemoral instability risk factors but also a significantly increased sTTTG compared with patients without TD. LEVEL OF EVIDENCE: Level III, retrospective case comparative study.

Increased tibial tuberosity torsion has the greatest predictive value in patients with patellofemoral instability compared to other commonly assessed parameters.

PURPOSE: The multifactorial nature of patellofemoral instability requires a comprehensive assessment of the affected patients. While an association between tibial tuberosity (TT) torsion and patellofemoral instability is known, its specific effect has not yet been investigated. This study investigated the effect of TT torsion on patellofemoral instability. METHODS: This retrospective cohort study compared patients who underwent surgical intervention for patellofemoral instability and asymptomatic controls. TT torsion was measured in addition to other commonly assessed risk factors for patellofemoral instability using standardised computed tomography (CT) data of the lower extremities. The diagnostic performances of the assessed parameters were evaluated using receiver operating characteristic curve analysis and odds ratios (ORs) were calculated. RESULTS: The patellofemoral instability group consisted of 79 knees, compared to 72 knees in the asymptomatic control group. Both groups differed significantly in all assessed parameters (p < 0.001), except for tibial torsion (n.s.). Among all parameters, TT torsion presented the best diagnostic performance for predicting patellar instability with an area under the curve of 0.95 (95% confidence interval [CI], 0.91-0.98; p < 0.001). A cut-off value of 17.7° yielded a 0.87 sensitivity and 0.89 specificity to predict patellar instability (OR, 55.2; 95% CI, 20.5-148.6; p < 0.001). CONCLUSION: Among the evaluated risk factors, TT torsion had the highest predictive value for patellofemoral instability. Patients with TT torsions ≥ 17.7° showed a 55-fold increased probability of patellofemoral instability. Therefore, TT torsion should be included in the assessment of patients with patellofemoral instability. LEVEL OF EVIDENCE: Level III.

No significant change of tibiofemoral rotation after femoral rotational osteotomy in patients with patellofemoral instability.

PURPOSE: An increased value of tibiofemoral rotation is frequently observed in patients with patellofemoral instability or maltracking. Nevertheless, the appropriate approach for addressing this parameter remains unclear so far. One potential approach for correcting tibiofemoral rotation is femoral rotational osteotomy. We hypothesized that femoral rotational osteotomy affects tibiofemoral rotation. METHODS: All patients who underwent femoral rotational osteotomy between January 2018 and May 2022 were included in this study. Pre- and postoperative tibiofemoral rotation and the degree of femoral rotation were measured using two-dimensional (2D) and three-dimensional (3D) measurements. The effect of femoral rotation on tibiofemoral rotation was assessed. RESULTS: Forty knees (18 right and 22 left) of 36 patients (28 females and 8 males) were included. Mean preoperative femoral torsion was 32.1 ± 10.1° in 2D and 30.8 ± 10.1° in 3D. Femoral rotation was performed by -14.1 ± 8.3° using 2D measurements and -15.0 ± 8.0° using 3D measurements. Tibiofemoral rotation changed from 9.9 ± 6.2° to 9.7 ± 6.0° (p = n.s.) in 2D, and from 10.2 ± 5.5° to 9.4 ± 5.4° (p = n.s.) in 3D. CONCLUSION: Tibiofemoral rotation showed no significant changes after femoral rotational osteotomy. Hence, femoral rotational osteotomy cannot be used to correct tibiofemoral rotation in addition to correcting the femoral version. Other surgical techniques need to be evaluated if correction of tibiofemoral rotation is required. LEVEL OF EVIDENCE: Level III.

Registration based assessment of femoral torsion for rotational osteotomies based on the contralateral anatomy.

BACKGROUND: Computer-assisted techniques for surgical treatment of femoral deformities have become increasingly important. In state-of-the-art 3D deformity assessments, the contralateral side is used as template for correction as it commonly represents normal anatomy. Contributing to this, an iterative closest point (ICP) algorithm is used for registration. However, the anatomical sections of the femur with idiosyncratic features, which allow for a consistent deformity assessment with ICP algorithms being unknown. Furthermore, if there is a side-to-side difference, this is not considered in error quantification. The aim of this study was to analyze the influence and value of the different sections of the femur in 3D assessment of femoral deformities based on the contralateral anatomy. MATERIAL AND METHODS: 3D triangular surface models were created from CT of 100 paired femurs (50 cadavers) without pathological anatomy. The femurs were divided into sections of eponymous anatomy of a predefined percentage of the whole femoral length. A surface registration algorithm was applied to superimpose the ipsilateral on the contralateral side. We evaluated 3D femoral contralateral registration (FCR) errors, defined as difference in 3D rotation of the respective femoral section before and after registration to the contralateral side. To compare this method, we quantified the landmark-based femoral torsion (LB FT). This was defined as the intra-individual difference in overall femoral torsion using with a landmark-based method. RESULTS: Contralateral rotational deviation ranged from 0° to 9.3° of the assessed femoral sections, depending on the section. Among the sections, the FCR error using the proximal diaphyseal area for registration was larger than any other sectional error. A combination of the lesser trochanter and the proximal diaphyseal area showed the smallest error. The LB FT error was significantly larger than any sectional error (p < 0.001). CONCLUSION: We demonstrated that if the contralateral femur is used as reconstruction template, the built-in errors with the registration-based approach are smaller than the intraindividual difference of the femoral torsion between both sides. The errors are depending on the section and their idiosyncratic features used for registration. For rotational osteotomies a combination of the lesser trochanter and the proximal diaphyseal area sections seems to allow for a reconstruction with a minimal error.

The effect of native knee rotation on the tibial-tubercle-trochlear-groove distance in patients with patellar instability: an analysis of MRI and CT measurements.

BACKGROUND: This study aimed to quantify the effect of lower limb rotational parameters on the difference in the tibial-tubercle-trochlear-groove (TTTG) distance when assessed with magnetic resonance imaging (MRI) and computed tomography (CT) in patients with patellar instability. It was hypothesized that an increased native knee rotation angle significantly contributes to an underestimation of TTTG by MRI. METHODS: Forty patients with patellar instability who had undergone standard radiographs, MRI and CT scans were included in this retrospective study. A musculoskeletal radiologist assessed all imaging for TTTG, femoral and tibial rotation, knee rotation and flexion angle, and trochlear dysplasia. ΔTTTG was defined as the TTTG measured on MRI subtracted from the TTTG measured on CT. Statistical analysis determined the effect of these parameters on the calculated difference between TTTG when measured on CT and MRI. RESULTS: Equal knee flexion in MRI and CT resulted in a ΔTTTG of 0.1 ± 0.3 mm compared to 4.0 ± 3.3 mm in patients with different knee flexion angles in both imaging acquisitions (p = 0.036). The knee rotation angle measured on CT (native knee rotation angle) was negatively correlated with ΔTTTG (r = - 0.365; p = 0.002), while neither tibial nor femoral rotation showed any associations with TTTG (n.s.). Trochlear dysplasia did not show any significant correlation with ΔTTTG, regardless of classification by Dejour or Lippacher (n.s.). Both the native knee rotation angle and the MRI knee flexion angle were independent predictors of ΔTTTG, yet with an opposing effect (knee rotation: 95% Confidence Interval [CI] for ß - 0.468 to - 0.154, p < 0.001; knee flexion 95% CI for ß 0.292 to 0.587, p < 0.001). Patients with a native knee rotation angle > 20° showed a ΔTTTG of - 5.8 ± 4.0 mm (MRI rather overestimates TTTG) compared to 0.9 ± 4.1 mm Δ TTTG (MRI rather underestimates TTTG) in patients with < 20° native knee rotation angle. CONCLUSION: The native knee rotation angle is an independent, inversely correlated predictor of ΔTTTG, thus opposing the effect of knee flexion during MRI acquisition. Consequently, these results suggest that not only knee flexion but also knee rotation should be appreciated when assessing TTTG during patellar instability diagnostic evaluation as it can potentially lead to a false estimation of the TTTG distance on MRI. LEVEL OF EVIDENCE: Level III.

Is the contralateral lesser trochanter a reliable reference for planning of total hip arthroplasty - a 3-dimensional analysis.

BACKGROUND: Preoperative templating in total hip arthroplasty (THA) is mandatory to achieve appropriate offset and leg length equality. However, templating methods using the contralateral hip might be susceptible to errors resulting from side-differences in the femoral morphology. The distance of the lesser trochanter to the femoral head center (LTFHD) is a frequently used reference parameter for preoperative planning and intraoperative validation during THA. However, currently no three-dimensional (3D) analysis of side differences of the LTFHD exists. METHODS: Using Computer tomography (CT)-based surface models from 100 paired femora (50 cadavers), side-to-side asymmetry of the LTFHD, femoral length, femoral head diameter (FHD) and femoral antetorsion were analyzed. Univariate linear regression models were established to evaluate potential associations between sides regarding LTFHD and FHD as well as a correlation of these parameters with each other. RESULTS: Statistically significant side-differences were found for the LTFHD (p = 0.02) and FHD (p = 0.03) with a mean absolute side-difference of 1.6 ± 1.4mm (range 0.1-5.5mm) and 0.4mm ± 0.6mm (range 0-3mm), respectively. The ratio between the LTFHD and FHD was consistent with an average value of 1.16 ± 0.08 and reliable between sides with a correlation coefficient (r) of 0.72 (p < 0.01). CONCLUSIONS: The LTFHD is a reliable reference parameter for preoperative templating and intraoperative validation during THA with a high correlation between sides (r = 0.93, p < 0.01). However, 8 % of the investigated specimens revealed a LTFHD of more than 4mm, which should be anticipated during THA to avoid unsatisfiable results.

Femoral interference screw insertion significantly increases graft tension in medial patellofemoral ligament reconstruction.

PURPOSE: This study aimed to quantify the effect of interference screw insertion on MPFL graft tension when securing the femoral attachment after patellar fixation. It was hypothesized that interference screw insertion significantly increases graft tension. METHODS: Ten fresh frozen human cadaveric femurs were utilized to compare graft tension at three different preloading conditions (2 N, 5 N, 10 N) using a tensile testing machine (Admet Inc., Norwood, MA). Each preloading condition was analyzed with varying graft sizes (5-8 mm), tunnel diameters (7-9 mm), and interference screw sizes (7-9 mm). Non-parametric statistical analysis was utilized to compare testing conditions among each other. RESULTS: Graft tension significantly increased after interference screw insertion by 100% to 552%, with 2 N preload showing the greatest increase (p < 0.001). Grafts with a larger diameter (7-8 mm) had a significantly greater increase in tension than smaller grafts (5-6 mm), regardless of preloading conditions (p < 0.001). Interference screw size had no influence on graft tension (n.s.). A graft-tunnel interference (tunnel diameter-graft diameter) fit of 0 mm and 1 mm significantly increased graft tension for each preloading condition when compared to a slightly looser fit of ≥ 2 mm (p < 0.05). CONCLUSION: Femoral interference screw insertion significantly increases graft tension in MPFL reconstruction even in low preloading conditions, with graft size and graft-tunnel interference fit having a considerably effect on graft tension. Surgeons should be aware of the inadvertent increases in graft tension even in low preloading conditions to mitigate the risk of graft overtensioning.

The Effect of Mechanical Leg Alignment on Cartilage Restoration With and Without Concomitant High Tibial Osteotomy.

PURPOSE: To assess graft survivorship in patients who underwent autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation (OCA) for the treatment of focal full-thickness cartilage lesions on the medial femoral condyle with and without concomitant high tibial osteotomy (HTO), depending on the preoperative lower-extremity alignment. A secondary purpose was to retrospectively evaluate associated factors for ACI and OCA graft failures. METHODS: A total of 168 patients who underwent cartilage repair with ACI or OCA with or without HTO for focal chondral defects on the medial femoral condyle by a single surgeon between March 2007 and February 2018 were included. Clinical notes, operative reports, and radiographic imaging were reviewed for each patient. Detailed Kaplan-Meier analyses were performed based on patient's mechanical axis alignment. In a subanalysis, failures and nonfailures in patients treated with ACI or OCA were comparatively evaluated. RESULTS: In ACI, neutral mechanical alignment resulted in a significantly longer graft survival compared with slight valgus alignment (P = .003 and P = .05, respectively). No significant differences in survivorship were seen based on mechanical axis alignment in OCA patients (P > .05). Patients who were considered failures after ACI presented significantly more often with valgus alignment (P = .002), whereas failures in the OCA group were more often female and smokers (P = .025; P = .034). CONCLUSIONS: In summary, the results of this study suggest that neutral mechanical axis alignment, regardless if physiologic or through HTO, improves survivorship in patients undergoing medial compartment ACI. Neutral alignment also showed a trend towards improved survivorship in patients after OCA, but this did not reach statistical significance. LEVEL OF EVIDENCE: Case-Series; Level of evidence, 4.

Trochlear Dysplasia Does Not Affect the Outcomes of Patellofemoral Autologous Chondrocyte Implantation.

PURPOSE: To evaluate the influence of trochlear dysplasia on clinical outcomes after autologous chondrocyte implantation (ACI) for the treatment of large cartilage lesions in the patellofemoral joint (PFJ) with a minimum of 2 years' follow-up. METHODS: We performed a retrospective review of prospectively collected data of all patients submitted to cartilage repair with ACI for focal cartilage defects in the PFJ by a single surgeon. Patient factors, lesion morphology, and preoperative and postoperative patient-reported outcome measures including the Knee Injury and Osteoarthritis Score, Lysholm score, Tegner activity level, and International Knee Documentation Committee Subjective Knee Evaluation Form score were collected. Two independent observers assessed preoperative imaging to determine the presence and grade of trochlear dysplasia. Patients were stratified into 2 groups based on the presence or absence of trochlear dysplasia. Patients without trochlear dysplasia served as controls. Patients were matched 1:1 for sex, age, body mass index, lesion size, and location. RESULTS: Forty-six patients who underwent ACI in the PFJ with a mean follow-up period of 3.7 ± 1.9 years (range, 2-9 years) were enrolled in this study (23 in the trochlear dysplasia group vs 23 in the normal trochlea group). The patients' mean age was 30.1 ± 8.8 years. Patient-reported outcome measures at final follow-up did not differ between the 2 groups (P > .05). No difference in failure rates was seen between the 2 groups (n = 1 [4.3%] vs n = 1 [4.3%], P > .999). Additionally, no difference in clinical outcomes was seen between patients with high-grade dysplasia (19 patients; Dejour types B-D) and patients without dysplasia (19 patients) (P > .05). CONCLUSIONS: ACI in the PFJ provides favorable outcomes even in patients with trochlear dysplasia, which are comparable to those in patients with normal trochlear anatomy. Thus, trochlear dysplasia seems to not influence the clinical outcomes of ACI in the PFJ. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Effect of Autogenous Bone Marrow Aspirate Treatment on Magnetic Resonance Imaging Integration of Osteochondral Allografts in the Knee: A Matched Comparative Imaging Analysis.

PURPOSE: To accurately evaluate the effects of bone marrow aspirate (BMA) augmentation on osteochondral allograft (OCA) integration on early postoperative magnetic resonance imaging (MRI) using the comprehensive Osteochondral Allograft MRI Scoring System (OCAMRISS). METHODS: This imaging study compared patients who underwent OCA transplantation with and without BMA augmentation for the treatment of focal osteochondral defects in the knee performed by a single surgeon between July 2013 and July 2017. Patients were excluded if they underwent implantation of premade plugs, had an overlapping OCA configuration ("snowman" technique), or did not undergo MRI at 6 months postoperatively. Patients were matched by lesion location, lesion size, age, and body mass index, as well as whether they underwent previous surgical procedures. Data were analyzed using descriptive statistics, Spearman correlation, the independent t test, the Mann-Whitney U test, and the χ2 test. RESULTS: A total of 58 patients (29 per group) were included in this study, with an average age of 36.4 ± 10.1 years and mean body mass index of 28.6 ± 5.1. The mean size of the analyzed OCA plugs was 3.3 ± 1 cm2. At an average imaging follow-up of 5.6 ± 1 months, 86.2% of the grafts had achieved osseous integration at the graft-host junction and 75.9% did not show any cystic changes in the subchondral bone. No difference in any OCAMRISS subscale was seen comparing OCAs with and without BMA augmentation (P > .05). Specifically, osseous integration and subchondral cyst formation were comparable between groups (P = .128 and P = .539, respectively). CONCLUSIONS: OCAs showed excellent osseous integration at the graft-host junction on 6-month postoperative MRI. The treatment of OCAs with autogenous BMA did not result in superior imaging outcomes when analyzed using the OCAMRISS. LEVEL OF EVIDENCE: Level III, case-control study.

Open Meniscal Allograft Transplantation With Transosseous Suture Fixation of the Meniscal Body Significantly Decreases Meniscal Extrusion Rate Compared With Arthroscopic Technique.

PURPOSE: To assess and compare meniscal extrusion rates after lateral "bridge-in-slot" meniscal allograft transplantation (MAT) with arthroscopic versus open insertion. METHODS: In this review of prospectively collected data, we analyzed data from patients who underwent arthroscopic or open lateral MAT. Patients who underwent concomitant distal femoral osteotomy, for whom 1-year postoperative magnetic resonance imaging was unavailable, or who underwent open lateral MAT without the use of transosseous sutures were excluded. Meniscal extrusion in the included patients was assessed by 2 independent examiners by measuring the absolute value and the relative percentage of extrusion on 1.5-T magnetic resonance images at 1-year follow-up. The number of MATs with radial displacement larger or smaller than 3 mm was determined. RESULTS: A total of 20 patients met the inclusion criteria, of whom 10 underwent arthroscopic and 10 underwent open lateral MAT. No statistically significant differences were found in baseline demographic data. Absolute meniscal extrusion was similar between the groups (P = .091). A significantly larger relative percentage of extrusion (arthroscopic MAT, 31 ± 27 mm; open MAT, 10 ± 29 mm; 95% confidence interval, -0.4 to -0.02 mm; P = .03) and a significantly higher extrusion rate were found in patients treated with arthroscopic MAT than in those treated with open MAT (>3 mm in 5 patients [50%] with arthroscopic MAT and 0 patients with open MAT, P = .01). CONCLUSIONS: This study identified similar absolute extrusion and significantly lower postoperative lateral meniscal extrusion rates after open MAT compared with arthroscopic MAT. Transosseous fixation of the meniscal body appears protective against meniscal extrusion after MAT. LEVEL OF EVIDENCE: Level III, case-control study.

A multicenter study to evaluate subscapularis muscle function using 5:30 o'clock portal for antero-inferior shoulder stabilization.

INTRODUCTION: The purpose of this study was to compare the outcome after arthroscopic antero-inferior shoulder stabilization with and without using a 5:30 o'clock portal. MATERIALS AND METHODS: Sixty-two patients [age (mean ± SD), 28.05 ± 8.25 years] with a mean follow-up of 15.23 ± 5.02 months were included in this study. Thirty-one patients underwent arthroscopic antero-inferior shoulder stabilization using the 5:30 o'clock portal in center A (group I) and were compared to 31 matched patients managed with the 3 o'clock portal in center B (group II). Physical examination, standard shoulder scores, ultrasound assessment and subscapularis strength measurement were used to evaluate postoperative shoulder function. RESULTS: Good to excellent results were seen in both groups. No significant differences were seen when comparing ASES, Constant and Rowe Score of both groups. Patients of group II achieved a significant higher score in the SST than patients of group I. (p < 0.05) Patients of group I had a significantly lesser loss of passive external rotation in 0° and 90° of abduction. (p = 0.04; p = 0.056) Ultrasound evaluation and strength measurement showed no significant differences in subscapularis muscle integrity or function neither between the involved and uninvolved shoulder nor between both groups. CONCLUSION: Arthroscopic anterior-inferior shoulder stabilization results in excellent clinical results. When considering portal placement, the deep trans-subscapularis portal allows a more precise suture anchor placement at the inferior glenoid rim and capsular shift with a significant improved external rotation but does not negatively affect the subscapularis function in terms of internal rotation strength or structural integrity. LEVEL OF EVIDENCE: III.

Load Distribution After Serial Resection of the Posterior Horn of the Lateral Meniscus and Subsequent Meniscal Allograft Transplant: A Biomechanical Study.

BACKGROUND: Data are lacking as to when a meniscal allograft transplant (MAT) may be biomechanically superior to a partially resected lateral meniscus. HYPOTHESIS: Lateral MAT using a bone bridge technique would restore load distribution and contact pressures in the tibiofemoral joint to levels superior to those of a partial lateral meniscectomy. STUDY DESIGN: Controlled laboratory study. METHODS: Eleven fresh-frozen human cadaveric knees were evaluated in 5 lateral meniscal testing conditions (native, one-third posterior horn meniscectomy, two-thirds posterior horn meniscectomy, total meniscectomy, MAT) at 3 flexion angles (0°, 30°, and 60°) under a 1600-N axial load. Pressure sensors were used to acquire contact pressure, contact area, and peak contact pressure within the tibiofemoral joint. RESULTS: Limited (one-third and two-thirds) partial lateral posterior horn meniscectomy showed no significant increase in mean and peak contact pressures as well as no significant decrease in contact area compared with the intact state. Total meniscectomy significantly increased mean contact pressure at 0° and 30° (P = .008 and P < .001, respectively), increased peak contact pressure at 30° (P = .04), and decreased mean contact area in all flexion angles compared with the native condition (P < .01). Lateral MAT significantly improved mean contact pressure compared with total meniscectomy at 0° and 30° (P = .002 and P = .003, respectively) and increased contact area at 30° and 60° (P = .003 and P = .009, respectively), although contact area was still significantly smaller (24.1%) after MAT relative to the native meniscus (P = 0.015). However, allograft transplant did not result in better tibiofemoral contact biomechanics compared with limited partial meniscectomy (P > .05). CONCLUSION: The peripheral portion of the lateral meniscus provided the most important contribution to the distribution of contact pressure across the tibiofemoral joint in the cadaveric model. Total meniscectomy significantly increased mean and peak contact pressure in the cadaveric model and decreased contact area. Lateral MAT restored contact biomechanics close to normal but was not superior to the partially meniscectomized status. CLINICAL RELEVANCE: Surgeons should attempt to preserve a peripheral rim of the posterior lateral meniscus. Meniscal allograft transplant appears to improve but not normalize mean contact pressure and contact area relative to total lateral meniscectomy.

Conventional vs. endoscopic-assisted curettage of benign bone tumours. An experimental study.

BACKGROUND: This experimental study aimed at directly comparing conventional and endoscopic-assisted curettage towards (1) amount of residual tumour tissue (RTT) and (2) differences between techniques regarding surgical time and surgeons' experience level. METHODS: Three orthopaedic surgeons (trainee, consultant, senior consultant) performed both conventional (4x each) and endoscopic-assisted curettages (4x each) on specifically prepared cortical-soft cancellous femur and tibia sawbone models. "Tumours" consisted of radio-opaque polyurethane-based foam injected into prepared holes. Pre- and postinterventional CT-scans were carried out and RTT assessed on CT-scans. For statistical analyses, percentage of RTT in relation to total lesion's volume was used. T-tests, Wilcoxon rank-sum tests, and Kruskal-Wallis tests were applied to assess differences between surgeons and surgical techniques regarding RTT and timing. RESULTS: Median overall RTT was 1% (IQR 1 - 4%). Endoscopic-assisted curettage was associated with lower amount of RTT (median, 1%, IQR 0 - 5%) compared to conventional curettage (median, 4%, IQR 0 - 15%, p = 0.024). Mean surgical time was prolonged with endoscopic-assisted (9.2 ± 2.9 min) versus conventional curettage (5.9 ± 2.0 min; p = 0.004). No significant difference in RTT amount (p = 0.571) or curetting time (p = 0.251) depending on surgeons' experience level was found. CONCLUSIONS: Endoscopic-assisted curettage appears superior to conventional curettage regarding complete tissue removal, yet at expenses of prolonged curetting time. In clinical practice, this procedure may be reserved for cases at high risk of recurrence (e.g. anatomy, histology).

Typical Complications After Cartilage Repair of the Ankle Using Autologous Matrix-Induced Chondrogenesis (AMIC).

Background: Autologous matrix-induced chondrogenesis (AMIC) for the treatment of osteochondral lesions of the talus (OLT) results in favorable clinical outcomes, yet high reoperation rates. The aim of this study was to report and analyze typical complications and their risk factors after AMIC for OLT. Methods: A total of 127 consecutive patients with 130 AMIC procedures for OLT were retrospectively assessed. All AMIC procedures were performed in an open fashion with 106 (81.5%) cases requiring a malleolar osteotomy (OT) to access the OLT. Seventy-one patients (54.6%) underwent subsequent surgery. These cases were evaluated at a mean follow-up of 3.1 years (±2.5) for complications reviewing postoperative imaging and intraoperative findings during revision surgery. Six patients (8.5%) were lost to follow-up. Regression model analysis was conducted to identify factors that were associated with AMIC-related complications. Results: Among the 65 (50%) patients who required revision surgery, 18 patients (28%) demonstrated AMIC-related complications with deep fissuring (83%) and thinning (17%) of the AMIC graft. Conversely, 47 patients (72%) underwent subsequent surgery due to AMIC-unrelated reasons including isolated removal of symptomatic hardware (n = 17) and surgery addressing concomitant pathologies with (n = 25) and without hardware removal (n = 5). Previous prior cartilage repair surgery was significantly associated with AMIC graft-associated complications in patients undergoing revision surgery (P = .0023). Among age, body mass index, defect size, smoking, and bone grafting, smoking was the only factor showing statistical significance with an odds ratio of 3.7 (95% CI 1.24, 10.9; P = .019) to undergo revision surgery due to graft-related complications, when adjusted for previous cartilage repair surgery. Conclusion: The majority of revision surgeries after AMIC for OLT are unrelated to the performed AMIC graft but frequently address symptomatic hardware and concomitant pathologies. Both smoking and previous cartilage repair surgery seem to significantly increase the risk of undergoing revision surgery due to AMIC-related complications. Level of evidence: Level IV, case series.

Short-to Mid-Term Survivorship of a Patient-specific Unicompartmental Knee Arthroplasty Implant Cast from a Three-Dimensional Printed Mold.

The purpose of this study was to determine early survivorship and complication rates associated with the implantation of a new patient-specific unicompartmental knee implant cast from a three-dimensional (3D) printed mold, introduced in 2012. We retrospectively reviewed 92 consecutive patients who underwent unicompartmental knee arthroplasty (UKA) with a patient-specific implant cast from a 3D printed mold between September 2012 and October 2015. The early results of a patient-specific UKA implant were favorable in our cohort, with survivorship free from reoperation of 97% at an average 4.5 years follow-up. Future studies are necessary to investigate the long-term performance of this implant. Survivorship of a patient-specific unicompartmental knee arthroplasty implant cast from a 3D printed mold.

Restoration of Native Leg Length After Opening-Wedge High Tibial Osteotomy: An Intraindividual Analysis.

BACKGROUND: Opening-wedge high tibial osteotomy (OWHTO) has been shown to significantly increase leg length, especially in patients with large varus deformity. Thus, the current literature recommends closing-wedge high tibial osteotomy to correct malalignment in these patients to prevent postoperative leg length discrepancy. However, potential preoperative leg length discrepancy has not been considered yet. HYPOTHESIS: It was hypothesized that patients have a decreased preoperative length of the involved leg compared with the contralateral side and that OWHTO would subsequently restore native leg length. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included were 67 patients who underwent OWHTO for unilateral medial compartment knee osteoarthritis and who received full leg length assessment pre- and postoperatively. Patients with varus or valgus deformity (>3°) of the contralateral side were excluded. A musculoskeletal radiologist assessed imaging for the mechanical axis, full leg length, and tibial length of the involved and contralateral lower extremity. Statistical analysis determined the pre- and postoperative leg length discrepancy and the influence of the mechanical axis. RESULTS: Most patients (62.7%) had a decreased length of the involved leg, with a mean preoperative mechanical axis of 5.0° ± 2.9°. Length discrepancy averaged -2.2 ± 5.8 mm, indicating a shortened involved extremity (P = .003). OWHTO significantly increased the mean lengths of the tibia and lower limb by 3.6 ± 2.9 and 4.4 ± 4.7 mm (P < .001), leading to a postoperative tibial and full leg length discrepancy of 2.8 ± 4.3 mm and 2.2 ± 7.3 mm (P < .001 and P = .017, respectively). Preoperative leg length discrepancy was significantly correlated with the preoperative mechanical axis of the involved limb (r = 0.292; P = .016), and the amount of correction was significantly associated with leg lengthening after OWHTO (r = 0.319; P = .009). Patients with a varus deformity of ≥6.5° (n = 14) had a preoperative length discrepancy of -4.5 ± 1.6 mm (P < .001) that was reduced to 1.8 ± 3.5 mm (P = .08). CONCLUSION: Patients undergoing OWHTO have a preoperative leg length discrepancy that is directly associated with the varus deformity of the involved extremity. As OWHTO significantly increases leg length, restoration of native leg length can be achieved particularly in patients with large varus deformity.

Correlation of Postoperative Imaging With MRI and Clinical Outcome After Cartilage Repair of the Ankle: A Systematic Review and Meta-analysis.

Background: Magnetic resonance imaging (MRI) is commonly used for evaluation of ankle cartilage repair, yet its association with clinical outcome is controversial. This study analyzes the correlation between MRI and clinical outcome after cartilage repair of the talus including bone marrow stimulation, cell-based techniques, as well as restoration with allo- or autografting. Methods: A systematic search was performed in MEDLINE, Embase, and Cochrane Collaboration. Articles were screened for correlation of MRI and clinical outcome. Guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were used. Chi-square test and regression analysis were performed to identify variables that determine correlation between clinical and radiologic outcome. Results: Of 2687 articles, a total of 43 studies (total 1212 cases) were included with a mean Coleman score of 57 (range, 33-70). Overall, 93% were case series, and 5% were retrospective and 2% prospective cohort studies. Associations between clinical outcome and ≥1 imaging variable were found in 21 studies (49%). Of 24 studies (56%) using the composite magnetic resonance observation of cartilage repair tissue (MOCART) score, 7 (29%) reported a correlation of the composite score with clinical outcome. Defect fill was associated with clinical outcome in 5 studies (12%), and 5 studies (50%) reported a correlation of T2 mapping and clinical outcome. Advanced age, shorter follow-up, and larger study size were associated with established correlation between clinical and radiographic outcome (P = .021, P = .028, and P = .033). Conclusion: Interpreting MRI in prediction of clinical outcome in ankle cartilage repair remains challenging; however, it seems to hold some value in reflecting clinical outcome in patients with advanced age and/or at a shorter follow-up. Yet, further research is warranted to optimize postoperative MRI protocols and assessments allowing for a more comprehensive repair tissue evaluation, which eventually reflect clinical outcome in patients after cartilage repair of the ankle.Level of Evidence: Level III, systematic review and meta-analysis.

Association of Subchondral Changes With Age and Clinical Outcome in Patients With Osteochondral Fractures in the Knee: MRI Analysis at 1 to 10 Years Postoperatively.

Background: Predictive factors influencing outcomes after surgical fixation of osteochondral fractures (OCFs) in the knee, particularly time between injury and surgery, have not been determined. Purpose: To report imaging and clinical outcomes after OCF fixation and to assess the association between clinical scores and patient characteristics, lesion morphology, and appearance on magnetic resonance imaging (MRI) scans. Study Design: Case series; Level of evidence, 4. Methods: We assessed the clinical and imaging outcomes of 19 patients after screw fixation for OCFs in the knee at a minimum follow-up of 1 year. Patient characteristics, lesion morphology, and time from trauma to surgery were reviewed for each patient. At final follow-up, patients completed a 100-point visual analog scale (VAS) for pain, Tegner activity scale, Knee injury and Osteoarthritis Outcome Score (KOOS), and patient satisfaction survey. Postoperative MRI scans were assessed using the MOCART (magnetic resonance observation of cartilage repair tissue), Osteochondral Allograft MRI Scoring System, and bone marrow edema (BME) size. Results: The mean patient age at surgery was 21.3 ± 11.4 years, and the median time from trauma to surgery was 10 days (range, 0-143 days). The refixed OCF fragment failed in 1 (5.3%) patient on the lateral condyle at 15 months postoperatively. The mean follow-up for the remaining 18 patients was 4.7 ± 3.2 years, and postoperative outcomes were as follows: VAS pain score, 9.5 ± 17.9; Tegner score, 4.8 ± 2.3; KOOS-Pain, 85.9 ± 17.6, KOOS-Symptoms, 76.4 ± 16.1; KOOS-Activities of Daily Living, 90.3 ± 19.0; KOOS-Sport, 74.4 ± 25.4; and KOOS-Quality of Life, 55.9 ± 24.7. Overall, 84.2% were satisfied or very satisfied with outcomes. Patient age was significantly associated with KOOS subscale scores and subchondral imaging parameters including BME and presence of subchondral cysts, which in turn were the only imaging variables linked to clinical outcomes (P < .05). Time from injury to surgery was not correlated with clinical or imaging outcomes. Conclusion: Fixation of OCFs yielded acceptable clinical and imaging outcomes at a mean 5-year follow-up with seemingly little influence of delayed surgical treatment. Postoperative subchondral changes were significantly associated with clinical outcomes and were linked to patient age at surgery.

Long-Term Results and Failure Analysis of the Open Latarjet Procedure and Arthroscopic Bankart Repair in Adolescents.

BACKGROUND: The purpose of this study was to analyze the long-term results of arthroscopic Bankart repair compared with an open Latarjet procedure in adolescents who are at high risk for recurrent anterior shoulder instability. We hypothesized that the long-term stability rate of an open Latarjet procedure would be superior to that of arthroscopic Bankart repair. METHODS: Forty eligible patients (41 shoulders) with a mean age of 16.4 years (range, 13 to 18 years) underwent arthroscopic Bankart repair, and 37 patients (40 shoulders) with a mean age of 16.7 years (range, 14 to 18 years) underwent an open Latarjet procedure. Of these, 34 patients (35 shoulders) in the Bankart group and 30 patients (31 shoulders) in the Latarjet group with long-term follow-up were compared; the overall follow-up rate was 82%. Clinical and radiographic results were obtained after a mean follow-up of 12.2 years (range, 8 to 18 years). RESULTS: Treatment failure occurred in 20 shoulders (57%) in the Bankart repair group and in 2 shoulders (6%) in the open Latarjet procedure group (p < 0.001), representing a significantly higher revision rate for instability in the Bankart group (13) compared with the Latarjet group (1) (p < 0.001). In patients without recurrent shoulder instability (15 in the Bankart group and 29 in the Latarjet group), there was a significant improvement in the Constant score (p = 0.006 in the Bankart group and p < 0.001 in the Latarjet group) and Subjective Shoulder Value (p = 0.009 in the Bankart group and p < 0.001 in the Latarjet group), without any significant difference between the 2 groups. Younger age was the only variable significantly correlated with failure following a Bankart repair (p = 0.01). CONCLUSIONS: Adolescents are at a high risk for treatment failure after Bankart repair, and, therefore, the Latarjet procedure should be strongly considered as a primary procedure for recurrent anterior shoulder instability in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.