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.

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

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

Management 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.

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

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

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

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

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

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

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

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

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

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

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

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

A systematic review about telemedicine in orthopedics.

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

Risk of arthrofibrosis in anatomical anterior cruciate ligament reconstruction: the role of timing and meniscus suture.

BACKGROUND: The optimal timing of anterior cruciate ligament (ACL) reconstruction remains controversial. Several studies have shown that early surgery leads to an increased rate of arthrofibrosis and poorer postoperative function. Other studies found no correlation between time of surgery and arthrofibrosis. The influence of simultaneous meniscus treatment is also discussed. Aim of this study was to ascertain whether the timing of surgery and treatment of meniscus influences the occurrence rate of arthrofibrosis. METHODS: Two hundred and six patients could be included. These were split into two groups. Group 1: surgery within 6 weeks after ACL rupture (n = 68), group 2: surgery after more than 6 weeks (n = 68). In addition, 2 matched groups were created (n = 138 ). Follow-up was 12 months after surgery. The primary endpoint was the rate of subsequent arthrofibrosis procedures (arthroscopic arthrolysis). Secondary endpoints were knee function (knee osteoarthritis outcome score: KOOS), knee pain (numeric rating scale: NRS) and patient satisfaction measured on a 5 point Likert scale. RESULTS: In 6 of the 68 patients in group 1 (8.8%) and 3 of the 138 patients in group 2 (2.2%) a subsequent arthroscopic arthrolysis was performed (OR 4.4). A simultaneous meniscal suture was performed in 58 patients (30 of them in group 1). Five of the six patients with subsequent arthrolysis in group 1 received meniscal repair (OR for arthrolysis 3.4). There was no difference between the groups in terms of knee function (KOOS), pain (NRS) and patient satisfaction. CONCLUSION: The rate of subsequent arthroscopic arthrolysis was higher in the acute surgery group. However, most of these subsequent procedures were associated with meniscal repair at index surgery with a more restrictive rehabilitation protocol than after ACL reconstruction without meniscus repair. This allows the assessment that the meniscal suturing poses an increased risk. Therefore, this allows the conclusion that if using an anatomical surgical technique and considering the signs of inflammation with effusion, pain and movement deficit less than 90° there is no increased risk of arthrofibrosis.

[Quadriceps tendon rupture]. / Quadrizepssehnenruptur.

The quadriceps tendon often ruptures spontaneously without trauma, frequently following an eccentric load on the tendon (walking down stairs) in the case of a previous degenerative injury. Rupture after endoprosthetic knee replacement is a special etiological case. Predominantly men between 50 and 65 years of age are affected. Clinical signs are suprapatellar hematoma and the inability to actively straighten the knee. A typical examination finding is the "suprapatellar gap sign". Ultrasonography is the diagnostic imaging modality of first choice as it can be reliably visualize the rupture and the resulting hematoma. Magnetic resonance imaging has a high sensitivity and specificity for detecting quadriceps tendon ruptures. However, its limited availability should not delay therapy. The treatment of choice is surgical transosseous refixation of the tendon at the upper patellar pole. Following surgery, a straight splint, partial weight bearing and limited mobility are required for 6-8 weeks.

Midterm Effect of Mental Factors on Pain, Function, and Patient Satisfaction 5 Years After Uncomplicated Total Knee Arthroplasty.

BACKGROUND: The effects of psychological factors on the short-term outcome after uncomplicated total knee arthroplasty (TKA) have been described in several studies. However, the effects of mental factors on the midterm (5-year) outcome have not been described in the literature. This study was performed to examine the influence of pain catastrophizing, anxiety, depression symptoms, and somatization dysfunction on the outcome of TKA during a 5-year follow-up. METHODS: One hundred fifty patients were enrolled in this prospective study. The following mental parameters were assessed in all patients: pain catastrophizing (Pain Catastrophizing Scale), anxiety (State-Trait Anxiety Inventory), depressive symptoms and somatization dysfunction (Patient Health Questionnaire). The primary outcome measure was postoperative pain on a numerical rating scale. The secondary outcome measures were the Knee Injury and Osteoarthritis Outcome Score and patient satisfaction. Intergroup differences were tested using an independent t-test. Odds ratios were calculated to determine the probability of an unsatisfactory outcome. RESULTS: At the 5-year follow-up, only depressive symptoms and somatization dysfunction had a significant effect on postoperative pain (numerical rating scale score). This significant effect was also observed for the different Knee Injury and Osteoarthritis Outcome Score subscales and patient satisfaction (P = .010-.020). Pain catastrophizing and anxiety had only a small effect on the clinical outcome at 5 years postoperatively. CONCLUSION: The effects of psychopathological factors (depressive symptoms and somatization dysfunction) on the clinical outcome after uncomplicated TKA persist for up to 5 years. Preoperative screening for and subsequent treatment of these psychological disorders may improve patient-reported outcomes after TKA. LEVEL OF EVIDENCE: Level II, diagnostic study.

Anterior Cruciate Ligament Revision Surgery: Ipsilateral Quadriceps Versus Contralateral Semitendinosus-Gracilis Autografts.

PURPOSE: To evaluate the subjective outcomes, knee stability, and donor-site morbidity after revision ACL reconstruction using either autologous ipsilateral quadriceps tendon or contralateral semitendinosus-gracilis tendon. METHODS: A sample size calculation suggested that we needed 25 patients in each group to detect equality between both groups. Therefore, we evaluated 30 consecutive patients who underwent an ACL revision surgery with ipsilateral bone-quadriceps tendon grafts and 30 consecutive patients with the contralateral semitendinosus-gracilis grafts between January 2010 and December 2012. Because of follow-up and exclusion criteria, finally 51 patients were evaluated. All patients were followed prospectively for at least 2 years with KT1000 arthrometer testing and the International Knee Documentation Committee (IKDC) objective grading. At the 24-month follow-up, additional clinical scores were evaluated: the Knee Injury Osteoarthritis Outcome Score (KOOS), the Lysholm score, assessing pain during kneeling, and anterior knee pain. RESULTS: The KT1000 postoperative arthrometer side-to-side difference was 2.0 ± 1.2 mm for the quadriceps group and 3.0 ± 2.9 mm for the semitendinosus-gracilis group. The difference was not statistically significant (P = .461). There was also no difference in the rate of positive pivot-shift tests between groups (P = .661). The Lysholm score was 82.5 ± 18 in the quadriceps group and 73.8 ± 19 in the semitendinosus-gracilis group. The difference was not statistically significant (P = .060). There was also no significant difference in the single KOOS subscores, assessing pain while kneeling and anterior knee pain (included in the KOOS score). No rerupture occurred during follow-up. CONCLUSIONS: Revision ACL reconstruction using the quadriceps tendon graft showed clinical outcomes similar to those of the contralateral semitendinosus-gracilis graft in terms of knee stability and function. Thus, the bone-quadriceps tendon graft may be a good alternative to the contralateral semitendinosus-gracilis tendon graft for revision ACL reconstruction. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Influence of somatization and depressive symptoms on the course of pain within the first year after uncomplicated total knee replacement: a prospective study.

PURPOSE: Approximately 10-25 % of patients are reportedly dissatisfied with the results of bicondylar knee prosthesis implantation. The purpose of this study was to evaluate the effect of depressive symptoms and particularly somatization dysfunction on outcomes after total knee replacement (TKR). METHODS: One hundred fifty patients were enrolled in this prospective study. Pre-operatively, depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) and somatization was assessed using the PHQ-15. The primary outcome measure was self-assessed knee function evaluated with the Knee Osteoarthritis Outcome Score (KOOS). Pain was measured on a numerical rating scale (NRS). The secondary outcome measures were the KOOS subscales and patient satisfaction. Intergroup differences were tested using an independent t-test. The odds ratio was used to determine the probability of an unsatisfactory outcome. RESULTS: At 12 months post-operatively, patients with depressive symptoms and particularly patients with somatization dysfunction usually had a significantly higher NRS score at rest and during activities, a lower knee function before and after surgery, and higher dissatisfaction. CONCLUSIONS: Psychopathologic factors, particularly somatization dysfunction, have an impact on TKR outcomes. Preoperative screening and concurrent treatment of the diagnosed psychological disorder may improve patient-perceived outcomes.

[Treatment of acute injury of the anterior cruciate ligament : Always only reconstruction?] / Behandlung der akuten Verletzung des vorderen Kreuzbands : Immer nur Rekonstruktion?

The aim of treatment of a ruptured anterior cruciate ligament (ACL) is the return of the patient to an acceptable level of activity without giving way phenomena as well as adequate treatment of prognostically relevant concomitant lesions. The treatment of acute ACL ruptures can be either early reconstruction or a primary physiotherapy with optional later reconstruction. Which path is taken depends on possible concomitant injuries that require early surgical intervention (e.g., repairable meniscal injury or distal rupture of the medial collateral ligament) and on patient-specific factors (age, level of activity). Isolated ruptures of the ACL can also be primarily treated without surgery. Then the injured knee joint should first be so far conditioned by rehabilitative measures that pain, swelling and posttraumatic restriction of movement are improved and neuromuscular training can be started. A screening test consisting of jumping tests, patient-reported outcome measures and the testing for giving way phenomena can be suitable to differentiate compensators (copers) from noncompensators (non-copers). Surgical reconstruction of the ACL should be recommended to non-compensators in the sense of participatory decision-making. Activity modification (adapter) can also be considered as a treatment strategy. If instability events (giving way) or secondary meniscal lesions occur during nonsurgical therapy, cruciate ligament reconstruction should be considered.

[Modified pendulum osteotomy to correct severe tibial varus deformity]. / Modifizierte Pendelosteotomie zur Korrektur einer hochgradigen tibialen Varusdeformität.

OBJECTIVE: Correction of a severe tibial varus deformity near the knee joint with only a slight influence on leg length and patella height. INDICATIONS: Medial osteoarthritis and/or cartilage damage with a severe varus deformity > 10° with a medial proximal tibial angle (MPTA) < 80°. CONTRAINDICATIONS: Femoral varus deformity with lateral distal femoral angle > 91°, severe lateral cartilage damage, lateral osteoarthritis, lateral meniscus loss. SURGICAL TECHNIQUE: Skin incision of approx. 8-10 cm between the tibial tuberosity and the head of the fibula. Exploration of the peroneal nerve. Detachment of the extensors. Insertion of an obliquely ascending guidewire ending approximately 10 mm below the medial articular surface. Insertion of a second guidewire. This aims at the middle of the first wire (hemi wedge). Check the wire position under fluoroscopy. Osteotomy with an oscillating saw under cooling. Removal of the wedge and closure of the osteotomy. Percutaneous needling of the medial collateral ligament with a cannula to carefully lengthen the ligament. Check the correction result with a metal rod. Osteosynthesis with lateral angle-stable plate. POSTOPERATIVE MANAGEMENT: Partial weight-bearing with 10 kg for 6 weeks postoperatively, free range of motion. RESULTS: Reports from the literature show that good clinical results can be achieved with this procedure for severe tibial varus deformities. Postoperative leg length discrepancies are less common with this procedure than with laterally closing osteotomy.

[Reconstruction of the patellar tendon with autologous or allogeneic semitendinosus tendon transplant for chronic rupture]. / Rekonstruktion der Patellarsehne mit autologem oder allogenem Semitendinosussehnentransplantat bei chronischer Ruptur.

OBJECTIVE: Reconstruction of a patellar tendon defect in the event of a chronic rupture. INDICATIONS: Chronic rupture of the patellar tendon due to delayed diagnosis or failure of primary refixation with a dehiscence that does not allow for anatomical refixation without patellar tendon shortening. CONTRAINDICATIONS: Infection. SURGICAL TECHNIQUE: Approximately 15 cm long incision from the tibial tuberosity to the patella. Depicting the rupture. Debridement of the tendon and insertion. Suture in the quadriceps tendon and distalization of the patella. If sufficient distalization of the patella is not possible, optionally perform a VY-plasty of the quadriceps tendon. Measuring the dehiscence. Securing the height of the patella by applying a patellotibial cerclage (strong suture cord). Extension of an existing tendon stump using a Z-plasty. Creation of 2 bone tunnels (diameter approx. 5 mm) in the patella and the tibial tuberosity. Insertion of an autologous or allogeneic semitendinosus tendon transplant and securing it by knotting the retaining threads in front of the tibial tuberosity. POSTOPERATIVE MANAGEMENT: Six weeks of partial weight-bearing with 10 kg of body weight in a straight, removable splint. Range of movement: weeks 1-4 E/F 0-0-60°, weeks 5-6 E/F 0-0-90°. RESULTS: Seven patients who underwent this surgery as described above had a minimum follow-up of 2 years. Secondary lengthening of the quadriceps tendon had to be performed twice due to excessive retraction. All patients were able to perform active extension postoperatively. The Lysholm score rose from 49.3 to 83.2 points. No further rupture was detectable in the final ultrasound examination.

[Refixation of a posterior medial root lesion in combination with centralization by a meniscotibial suture]. / Refixation einer posterioren medialen Wurzelläsion in Kombination mit Zentralisation durch meniskotibiale Naht.

OBJECTIVE: Refixation of a posterior root lesion of the medial meniscus via a tibial drill tunnel and prevention of extrusion using a meniscotibial suture (centralization). INDICATIONS: Posterior root lesion of the medial meniscus. CONTRAINDICATIONS: Grade 4 cartilage damage in the corresponding compartment, uncorrected varus or valgus deformities, symptomatic instabilities, extensive degenerative tears apart from the root region. SURGICAL TECHNIQUE: Knee arthroscopy via the high anterolateral standard portal. Diagnostic arthroscopy to check indication. Locate the insertion zone on the tibial plateau and local debridement until the bone of the tibial plateau is visible. Insertion of a targeting device and drilling of a targeting wire into the center of the insertion zone in the area of the intercondylar eminence. Overdrill the target wire with a 4.5 mm drill. Reinforcement of the medial meniscus posterior horn with braided suture material. The reinforcing thread is inserted into the bone tunnel via an eyelet wire with a thread loop. Optional additional centralization with incision in the middle part of the meniscus. Reinforcement of the meniscus base with braided suture material using the "outside in" technique and fixation of the inner meniscus base at the edge of the tibial plateau using a transosseous extraction suture or a suture anchor. POSTOPERATIVE MANAGEMENT: Six weeks nonweight-bearing (0 kg), then gradually increased load. Range of motion: 4 weeks E/F 0-0-60°, 2 weeks 0-0-90°, optionally use of a valgus brace (varus of < 5°). RESULTS: In root lesions of the medial meniscus, transosseous refixation significantly improves knee function (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, visual analog scale for pain, Tegner, and Knee Injury and Osteoarthritis Outcome scores) and reduces osteoarthritis progression. However, a transosseous suture alone could not significantly reduce postoperative extrusion. However, previous studies have shown that additional centralization can significantly reduce extrusion.