Combined treatment with medial unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction is effective on long-term follow-up.

PURPOSE: The purpose of the present study was to evaluate the long-term outcome of combined medial unicompartmental knee arthroplasty (UKA) and anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that the combined procedure leads to good long-term outcome in patients with isolated medial knee osteoarthritis (OA) and anterior cruciate ligament (ACL) deficiency. METHODS: Twenty-three patients with ACL deficiency and concomitant medial knee OA were treated from 2008 to 2016 with a combined UKA (Oxford Partial Knee) and ACLR using a hamstring tendon autograft. The follow-up assessment included VAS pain score, Lysholm score, Oxford Knee Score (OKS), American Knee Society scores (AKSS), International Knee Documentation Committee (IKDC 2000), Tegner and UCLA activity scores. Instrumented laxity test was done using the KT-1000 arthrometer. Survivorship analysis was performed using the Kaplan-Meier method. Implant loosening and disease progression was assessed by conventional radiography. RESULTS: Average follow-up duration was 10 years (6-14.5). VAS, Lysholm, Tegner and UCLA scores improved significantly. OKS, AKSS and IKDC 2000 showed excellent results on follow-up. Implant survivorship was 91.4% at 14.5 years. There were 2 revisions with conversion to total knee arthroplasty at 6 and 12 years postoperatively due to trauma and disease progression, respectively. There were no radiological or clinical signs of instability or disease progression in any of the remaining knees. The side-to-side difference using the KT-1000 arthrometer was insignificant. CONCLUSIONS: UKA combined with ACLR is an effective therapeutic option with good outcome and return to sport rate on the long-term. LEVEL OF EVIDENCE: IV.

The Ali Krogius procedure for treatment of patellofemoral instability should be regarded as obsolete even in skeletally immature patients.

BACKGROUND: Several interventions are established for treating patellofemoral instability in adults. Fewer exist for pediatric patients without damaging the epiphysis. The Ali Krogius (AK) method is currently still being used. Most studies are not current and report varying results in small patient population. The aim of this study is to determine the long-term results of the AK method. METHODS: In this monocentric, retrospective study design, 33 knees in 33 patients who received the AK procedure for recurrent patellar dislocation were assessed. The average age was 20.8 years (range 6-40). The following functional scores were assessed: Kujala Score, Lysholm Score and Tegner Score. Subgroup analysis was done for patients ≤16 years of age. Available preoperative imaging was assessed for known risk factors. RESULTS: After an average follow-up of 7.8 years (Range 59-145 months), a total of 8 (24%) knees suffered a redislocation postoperatively. Seven of the eight dislocations occurred in patients ≤ 16 years of age. One knee (3%) was revised due to persistent pain. The median score was 86 points for the Kujala score and 90 for the Lysholm score. The median in the Tegner score was level 6. Clinically, the patellar glide was lateralized in 7 knees (21%) and an apprehension sign was triggered in 8 knees (24%). CONCLUSIONS: Including the present study, the existing literature indicates a redislocation rate between 24 and 41% following AK. It should thus be regarded as obsolete even though it protects the epiphysis. Surgical interventions such as medial patellofemoral ligament reconstruction with femoral drilling distal to the epiphysis should be preferred. TRIAL REGISTRATION: Retrospectively registered: S-302/2016. LEVEL OF EVIDENCE: III.

Feasibility of using half-dose Gd-BOPTA for delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) at the knee, compared with standard-dose Gd-DTPA.

BACKGROUND: We sought to replace full-dose Gd-DTPA with safer and lower-dose contrast agents for delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). Gd-BOPTA has a lower intrinsic nephrogenic systemic fibrosis risk and a 2-fold higher relaxivity at 3T; thus, the contrast agent dose may be halved, further reducing contrast agent-dependent risks. PURPOSE: To compare the feasibility of using half-dose, high-relaxivity Gd-BOPTA vs. standard-dose Gd-DTPA for dGEMRIC. STUDY TYPE: Prospective observational study. SUBJECTS: Eleven healthy volunteers (five women, mean age 25.7 years) and 10 patients with knee pain (three women, mean age 36.7 years; nine with chondromalacia). FIELD STRENGTH/SEQUENCES: 3D T1 -weighted volumetric breath-hold examination (VIBE) sequence at 3T. ASSESSMENT: Knee dGEMRIC was performed twice, first using 0.1 mmol/kg Gd-BOPTA and 4 weeks later using 0.2 mmol/kg Gd-DTPA. Contrast penetration was studied using pre- and 60-120-min postcontrast imaging in volunteers and pre- and 90-min postcontrast imaging in patients. Femoral cartilage lesions were assessed using modified whole-organ MRI scores. Healthy cartilage and partial-thickness lesions were compared using region-of-interest analyses by independent readers. STATISTICAL TESTS: Linear mixed-effect-models, area under receiver-operating-characteristic curve (AUC) analysis, intraclass correlation (ICC). RESULTS: In healthy volunteers, Gd-BOPTA and Gd-DTPA T1 -values did not differ significantly at any timepoint (P = 0.164-0.995). In patients, Gd-BOPTA T1 -values (743.33 ± 72.015 msec) were higher than Gd-DTPA T1 -values (681.24 ± 67.635 msec, P = 0.030). Gd-BOPTA and Gd-DTPA detected chondromalacia areas equally well, with significantly lower T1 -values than in healthy cartilage (P < 0.001) and nonsignificantly different AUCs (0.92 and 0.96, P = 0.27). The absolute decrease in T1 -values between healthy and pathological cartilage was similar (Gd-BOPTA: 149.59 msec; Gd-DTPA: 149.44 msec, P = 0.99). ICCs were 0.83-0.98 for Gd-BOPTA and 0.80-0.98 for Gd-DTPA. DATA CONCLUSION: Gd-BOPTA might be used at half the Gd-DTPA dose in dGEMRIC, with similar contrast penetration and T1 -values in healthy cartilage and noninferior detection of cartilage damage. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2020;51:144-154.

Quadriceps tendon vs. patellar tendon autograft for ACL reconstruction using a hardware-free press-fit fixation technique: comparable stability, function and return-to-sport level but less donor site morbidity in athletes after 10 years.

INTRODUCTION: The use of quadriceps tendon-patellar bone (QTB) autograft for anterior cruciate ligament (ACL) reconstruction is gaining momentum. Yet, long-term results that compare this procedure with established methods are lacking. The aim of this study was to report and compare long-term results of ACL reconstruction using QTB autografts versus bone-patellar tendon-bone (BPTB) autografts, both anchored using a hardware-free press-fit fixation technique. MATERIALS AND METHODS: 60 athletes (Tegner score ≥6) with primary ACL rupture were prospectively randomized into two groups. 56 patients were evaluated after a mean duration of 12.2 ± 1.9 months (range 10-14) and 43 patients after 10.3 ± 0.2 years (range 10-11). RESULTS: On final follow-up, 90% of patients scored very good and good results in the functional Lysholm score (mean 99 ± 7.1, range 74-100 points). Normal or almost normal IKDC score was reported by 84% of the patients (mean 97 ± 9.5, range 60-100 points). The activity level decreased in the Tegner score from median of 7 before injury to 6 after 10 years. The KT-1000 arthrometer showed a difference in the anterior translation of less than 3 mm (mean 1.0 ± 1.2, range - 1 to 5 mm) in 91% of the patients. Significant degeneration was radiologically detected in one patient per group. No tunnel widening was seen in any patient. Up to 97% of all patients were satisfied with the operative procedure. No significant differences were found in the mentioned parameters between the two groups and also in comparison with the 1-year results. The only significant difference was in the donor site morbidity. Significantly more patients in the BPTB group had complaints during kneeling both at 1 (p < 0.001) and 10 years (p = 0.019). Squatting was also subjectively more problematic in the BPTB group than in the QTB group both after 1 (p = 0.003) and 10 years (p = 0.046). CONCLUSIONS: This study shows equally good functional, clinical and radiological long-term results for both hardware-free methods of ACL reconstruction. These results clinically confirm the safety of press-fit anchoring after 10 years. The failure rate in this study was very low, with only one re-rupture in 10 years. The increased donor site morbidity when using the BPTB autograft compared to the QTB autograft supports already reported data. It was also seen in this study for the implant-free press-fit techniques. STUDY DESIGN: Prospective and randomized, level of evidence 2.

Revision ACL reconstruction using quadriceps or hamstring autografts leads to similar results after 4 years: good objective stability but low rate of return to pre-injury sport level.

PURPOSE: Due to the increased importance of revision ACL reconstruction, this study aims to evaluate the outcome 4 years after the surgery, compare two revision strategies and identify factors that influence the results. METHODS: Seventy-nine patients who received a revision ACL reconstruction were retrospectively evaluated. All patients were assessed with an average follow-up of 4.4 years (range 3.3-5.5 years). The results of patients treated with a quadriceps autograft were compared with those treated with a hamstring autograft. RESULTS: Ninety-seven percent of patients had a KT-1000 side-to-side difference of ≤ 5 mm (mean 1.7 ± 2.0 mm). Pivot-shift test was absent or minor in 95%. In the SLTH-test, 70% of patients reached 90% of the contralateral side. The mean Lysholm score on follow-up was 83 ± 12 (56% excellent/good). The mean IKDC 2000 subjective evaluation score was 81 ± 14 (58% normal/almost normal). The median Tegner activity score was 6 (range 3-10), a median of 2 levels worse than before the first injury. Return to sport rate was 89% but only 34% of patients reached their pre-injury sport level. Most common cause for this reduction was fear of another injury. Three patients suffered a re-rupture. Patients with a hamstring autograft performed pivoting sports more often, but had worse pivot-shift results compared to those with a quadriceps autograft. No significant influence was seen for other parameters. Young, male patients with a high activity level and no chondral damage had the best results. CONCLUSION: Through revision ACL reconstruction, the goal of stabilizing the knee can be achieved in the majority of patients. However, a good function and a high activity level are significantly less common in these patients. The main reason for this is fear of a renewed ACL-injury. Both quadriceps and hamstring autografts were able to achieve a good outcome. Young, male, patients with a normal BMI, a high activity level and without cartilage damage seem to benefit the most from revision ACL surgery. The discrepancy between the good laxity restoration and the lower activity rate should therefore be a main point in clinical counseling when deciding for or against revision ACL-Reconstruction. LEVEL OF EVIDENCE: III.

[What does the clinician expect from the radiologist regarding cartilage-specific imaging?] / Was erwartet der Kliniker vom Radiologen bei der dezidierten Knorpelbildgebung?

CLINICAL ISSUE: Today's advanced MRI imaging allows for a precise diagnosis and thus better treatment planning of cartilage damage. The phrase "depending on intraoperative findings" is therefore slowly becoming a thing of the past. However, this also increases the demand for an exact interpretation of the imaging, from clinicians and patients alike. This article highlights the importance of a radiologist's role in different constellations. PRACTICAL RECOMMENDATIONS: In the case of acute injuries, it is crucial to recognize osteochondral flakes, cartilage delamination, subchondral bone bruising and fractures as well as concomitant injuries. These findings must be instantly communicated to the practitioner. In the case of chronic cartilage damage, grading the extent and size of the damage is decisive in choosing the appropriate therapy method. Possible causes and accompanying injuries must also be analyzed and, if necessary, addressed. Direct communication with the clinical colleague is also useful in correlating the clinical and radiological findings.

Long-term follow-up after anterior cruciate ligament reconstruction using a press-fit quadriceps tendon-patellar bone autograft.

BACKGROUND: The use of a quadriceps tendon-patellar bone (QTPB) autograft provides an alternative procedure in primary reconstruction of the anterior cruciate ligament (ACL). Using the press-fit technique for femoral fixation and knotting over a bone bridge as well as additional spongiosa filling for tibial fixation can completely eliminate the need for fixation implants. The objective of this study was to evaluate the long-term clinical, functional and radiological results of this operating method. METHODS: Sixty-nine patients (27 female-42 male) were included in this study. Fifty-seven patients (83%) received a comprehensive follow-up review after an average period of 7.5 years (range: 7-8.7). All other patients were surveyed by telephone. Six patients (9%) suffered a re-rupture of the ACL graft caused by a new related trauma and were therefore excluded from the statistical analysis. RESULTS: Of all patients, 98% were satisfied with the operation. Normal or almost normal results were recorded in the subjective IKDC scores form by 88% of the patients. The Lysholm score demonstrated very good and good results in 83% of the patients. Only 1 patient reported minor complaints in the donor area. Seven (12%) patients developed Cyclops syndrome with limited knee extension. This complication was treated arthroscopically within the first year postoperatively. Their results on follow-up were not worse than the results of the patients without Cyclops syndrome. Regarding the 57 patients who received a comprehensive evaluation, the stability test with the KT-1000 Arthrometer yielded a difference of less than 3 mm in the contralateral comparison for 89% of the operated knees. The pivot-shift test was normal in 79% and almost normal in 21%. In the Single-leg Triple Hop Test, patients achieved an average of 98% of the hopping distance attained with the contralateral leg. The radiological examination revealed a slight deterioration in the Kellgren-Lawrence Score in 2 patients. CONCLUSION: The ACL reconstruction using the QTPB autograft performed with the press-fit technique leads to good results in comparison with published results of established procedures for primary ACL surgery using other autografts. Further investigations should involve comparative studies with the objective of providing evidence-based, individually adapted therapy for ACL rupture.

Feasibility of gadoteric acid for delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) at the wrist and knee and comparison with Gd-DTPA.

PURPOSE: To assess the feasibility of gadoteric acid for delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and to compare the dGEMRIC values obtained using gadoteric acid with those obtained by an equimolar dose of Gd-DTPA. MATERIALS AND METHODS: At 3T, dGEMRIC of the wrist was performed twice using a T1 -weighted 3D-volumetric interpolated breath-hold examination sequence in 16 healthy volunteers (10 women; mean age 26.0 years) using gadoteric acid first and Gd-DTPA 3 weeks later. In addition, 24 patients with knee pain were examined using gadoteric acid (n = 12; seven women; mean age 45.8 years) or Gd-DTPA (n = 12; four women; mean age 47.1 years). T1 values, the relative decrease in T1 , and the delta R1 were compared using t-tests. Interobserver agreement was assessed using the intraclass correlation (ICC) between two independent readers. RESULTS: At the wrist, there was no significant difference in delta R1 values (0.34 ± 0.10/s, 95% confidence interval [0.30;0.38]/s for gadoteric acid and 0.32 ± 0.09 [0.29;0.35]/s for Gd-DTPA, P = 0.24) or the relative decrease in T1 (0.25 ± 0.06 [0.29;0.35] msec for gadoteric acid and 0.24 ± 0.05 [0.22;0.27] msec for Gd-DTPA, P = 0.35). High observer agreement was found at precontrast (ICC = 0.87, P < 0.001) and postcontrast (ICC = 0.89, P < 0.001). Similarly, at the knee, there was no significant difference in delta R1 (0.39 ± 0.18 [0.32;0.47]/s for gadoteric acid and 0.41 ± 0.09 [0.38;0.45]/s for Gd-DTPA, P = 0.59) or the relative decrease in T1 (0.30 ± 0.10 [0.26;0.34] msec for gadoteric acid and 0.33 ± 0.05 [0.30;0.35] msec for Gd-DTPA, P = 0.28). High ICCs of 0.96 (P < 0.01) were noted both at precontrast and postcontrast. CONCLUSION: dGEMRIC using gadoteric acid is feasible and yields comparable values when compared with Gd-DTPA. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1433-1440.

Long-term outcome of anterior cruciate ligament reconstruction with an autologous four-strand semitendinosus tendon autograft.

PURPOSE: Although the short- and mid-term outcomes of ACL reconstruction with a hamstring graft are promising, clinical investigations reporting the long-term results after ten years or longer are rare. Therefore we performed a retrospective single-blinded evaluation of ACL reconstruction using a four-stranded single-bundle reconstruction with a semitendinosus tendon graft with extracortical fixation. METHODS/RESULTS: At follow-up patients obtained at least the same level in the clinical outcome scores (Lysholm, IKDC, Tegner) compared to previous studies with a similar follow-up time using a STG graft. Furthermore there was no detectable difference in the incidence of osteoarthritis. Patients having a negative pivot shift test showed significantly fewer signs of radiographic osteoarthritis and better functional assessment scores. CONCLUSION: On the basis of our investigation, we conclude that the reconstruction of the ACL by a quadrupled semitendinosus tendon graft with extracortical anchorage can achieve excellent clinical and subjective results after a follow-up of ten years.

Functional outcome and athletic level after arthroscopic repair followed by triple pelvic osteotomy in patients with labral tears resulting from acetabular dysplasia.

BACKGROUND: Patients with acetabular dysplasia are at a higher risk of developing symptomatic labral tears. Isolated treatments that address these pathologies are well established. Combined treatment with hip reorientation osteotomy using Bernese periacetabular osteotomy in addition to arthroscopic labral repair show good results. Studies that report the outcome in patients who received both arthroscopic labral repair and a triple pelvic osteotomy (TPO) are lacking. The aim of this study is to investigate the short to midterm functional outcome and activity level in these patients. METHODS: This case series retrospectively included 8 patients (2 male, 6 female) with acetabular dysplasia (lateral center-edge angle [LCEA] ≤ 25°) and a labral tear on magnetic resonance arthrography (MRA). All patients underwent arthroscopic labral repair followed by TPO after an average period of 3 months (range 2-6). Average age at the time of surgery was 25 years (range 15-37). Patients were followed up and the following main parameters were assessed: LCEA, modified Harris hip score (mHSS), Tegner score, UCLA score, patient satisfaction on a scale of 1-4. RESULTS: The mean follow-up was 19 months (range 15-25). The mean LCEA increased from 18° to 37° (p < 0.0001). The mHSS improved from a mean of 79 to 94 on final follow-up (p = 0.00123). The Tegner and UCLA scores had a median of 4 and 5, respectively. The mean LCEA increased from 18° to 37° (p < 0.0001). The mean patient satisfaction was 3.6. CONCLUSION: Patients with evidence of a labral tear resulting from acetabular dysplasia benefit from arthroscopic repair followed by a TPO. The literature still lacks evidence that labral repair and reorientation osteotomy produce superior outcome compared to osteotomy alone. Treatment should consider clinical presentation in addition to radiological findings with emphasis on MRA.

Fixation of Unstable Femoral Juvenile Osteochondritis Dissecans Lesions with Bioabsorbable Pins-Clinical and Radiographic Outcomes.

Juvenile Osteochondritis Dissecans (JOCD) is a common reason for knee pain among children. The aim of this case study was to report on clinical and radiographic outcomes after fixation of an osteochondral fragment with bioabsorbable pins in children with open growth plates. We hypothesized that surgical treatment with this technique will result in good function, high rates of radiographic healing and high return to sport rates. A total of 13 knees in 12 patients (6 male, 6 female) with a median of 13 years (11, 17) were evaluated retrospectively at a minimum clinical follow-up of 24 months. Inclusion criteria were defined as open growth plates and an unstable osteochondral lesion grade III or IV. The clinical outcome was evaluated utilizing three standardized patient-reported outcome scores (Tegner Activity Scale [TAS], Knee Injury and Osteoarthritis Outcome Score [KOOS], Lysholm Score). All patients underwent magnetic resonance imaging 15 months (3, 34) after surgical treatment and defect healing was evaluated utilizing a modified version of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Due to the small sample size, the data was reported descriptively. The interobserver variability was calculated with the Spearman rank correlation coefficient. Comparisons were made with Wilcoxon sign rank test (or sign test). At final follow-up the median KOOS Score was 98% (79.2%, 100%) and the median Lysholm Score was 94 (69, 100) points. The Tegner Activity Scale was 7 (4, 10) points preoperatively and 7 (4,10) points postoperatively (p = 0.5). Complete bony ingrowth occurred in 9 knees (69%), complete cartilage defect repair in 10 knees (77%) and integration to the border zone was found in 11 knees (85%) 15 (3, 34) months following surgical treatment. Fixation of osteochondral fragments with bioabsorbable pins resulted in good functional and radiographic outcomes, a high return to sport- and a low complication rate among children with open growth plates.

Increased satellite cell apoptosis in vastus lateralis muscle after anterior cruciate ligament reconstruction.

OBJECTIVE: Recovery of the quadriceps femoris muscle after anterior ligament reconstruction is im-paired. The aim of this study was to investigate satellite cell content and function of the vastus lateralis muscle after anterior ligament reconstruction. METHODS: Biopsies were obtained from the vastus lateralis muscle of 16 recreational athletes immediately before and again 12 weeks after anterior ligament reconstruction. Total satellite cell number (Pax7+), activated (Pax7+/MyoD+), differentiating (Pax7-/MyoD+), and apoptotic (Pax7+/TUNEL+) satellite cells, myofibers expressing myosin heavy chain (MHC) I and II, and neonatal MHC (MHCneo) were determined immunohistochemically. RESULTS: After anterior ligament reconstruction, the number of apoptotic satellite cells was significantly (p = 0.019) increased, concomitant with a significant (p < 0.001) decrease in total satellite cell number, with no change in activated and differentiating satellite cell number. MHCneo+ myofibers tended towards an increase. CONCLUSION: Satellite cell apoptosis and the reduction in the satellite cell pool might provide an explanation for prolonged quadriceps muscle atrophy after anterior ligament reconstruction.

Gene expression changes in vastus lateralis muscle after different strength training regimes during rehabilitation following anterior cruciate ligament reconstruction.

Impaired muscle regeneration has repeatedly been described after anterior cruciate ligament reconstruction (ACL-R). The results of recent studies provided some evidence for negative alterations in knee extensor muscles after ACL-R causing persisting strength deficits in spite of the regain of muscle mass. Accordingly, we observed that 12 weeks of concentric/eccentric quadriceps strength training with eccentric overload (CON/ECC+) induced a significantly greater hypertrophy of the atrophied quadriceps muscle after ACL-R than conventional concentric/eccentric quadriceps strength training (CON/ECC). However, strength deficits persisted and there was an unexpected increase in the proportion of slow type I fibers instead of the expected shift towards a faster muscle phenotype after CON/ECC+. In order to shed further light on muscle recovery after ACL-R, the steady-state levels of 84 marker mRNAs were analyzed in biopsies obtained from the vastus lateralis muscle of 31 subjects before and after 12 weeks of CON/ECC+ (n = 18) or CON/ECC strength training (n = 13) during rehabilitation after ACL-R using a custom RT2 Profiler PCR array. Significant (p < 0.05) changes were detected in the expression of 26 mRNAs, several of them involved in muscle wasting/atrophy. A different pattern with regard to the strength training mode was observed for 16 mRNAs, indicating an enhanced hypertrophic stimulus, mechanical sensing or fast contractility after CON/ECC+. The effects of the type of autograft (quadriceps, QUAD, n = 19, or semitendinosus tendon, SEMI, n = 12) were reflected in the lower expression of 6 mRNAs involved in skeletal muscle hypertrophy or contractility in QUAD. In conclusion, the greater hypertrophic stimulus and mechanical stress induced by CON/ECC+ and a beginning shift towards a faster muscle phenotype after CON/ECC+ might be indicated by significant gene expression changes as well as still ongoing muscle wasting processes and a negative impact of QUAD autograft.

Transphyseal reconstruction of the anterior cruciate ligament in prepubescent athletes.

ACL reconstruction in adolescents undergoing or being beyond the final growth spurt can be performed as in adults without major concern of growth disturbance. Whereas for the young athlete with wide-open physis a lot of controversy still exists about the technical aspect of the procedure to minimise the risk of growth disturbance. Between 10/1997 and 10/2002 31 children graded Tanner stage 1 or 2 (median age 11 years) with an intraligamental rupture of the anterior cruciate ligament were enrolled. Seventeen patients with coexisting intraarticular damage (meniscus, osteochondral flake) underwent transphsyeal reconstruction of the ACL with the use of an autogenous semitendinosus tendon graft, whereas 14 patients without coexisting pathologies received a nonoperative regime. Growth disturbance, functional and radiographic outcome could be evaluated in 28 patients at a median of 70 months after initial treatment. No patient had clinical or radiological evidence for varus/valgus malalignment or leg length discrepancy. The mean of subsequent body growth within the study population was 20.3 cm. Patients operated on revealed significant (P < 0.05) better clinical (KT-1000 side-to-side difference, pivot shift) and functional results according to the IKDC (median, 95 vs. 87), Lysholm (median, 93 vs. 84) and the Tegner score. More than half of the conservatively treated patients (58%) had subsequent surgery due to persistent instability. Transphyseal reconstruction of intraligamental ACL ruptures with an autologous ST graft yielded superior clinical results if compared to a nonoperative treatment in immature prepubescent patients being Tanner stage 1 and 2.

Prospective Long-term Follow-up of Autologous Chondrocyte Implantation With Periosteum Versus Matrix-Associated Autologous Chondrocyte Implantation: A Randomized Clinical Trial.

BACKGROUND: Matrix-associated autologous chondrocyte implantation (MACI) is a further development of the original autologous chondrocyte implantation periosteal flap technique (ACI-P) for the treatment of articular cartilage defects. PURPOSE: We aimed to establish whether MACI or ACI-P provides superior long-term outcomes in terms of patient satisfaction, clinical assessment, and magnetic resonance imaging (MRI) evaluation. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 21 patients with cartilage defects at the femoral condyle were randomized to MACI (n = 11) or ACI-P (n = 10) between the years 2004 and 2006. Patients were assessed for subjective International Knee Documentation Committee (IKDC) score, Lysholm and Gillquist score, Tegner Activity Score, and 36-Item Short Form Health Survey (SF-36) preoperatively (T0), at 1 and 2 years postoperatively (T1, T2), and at the final follow-up 8 to 11 years after surgery (T3). Onset of osteoarthritis was determined using the Kellgren-Lawrence score and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and delayed gadolinium-enhanced MRI of cartilage was used to evaluate the cartilage. Adverse events were recorded to assess safety. RESULTS: There were 16 patients (MACI, n = 9; ACI-P, n = 7) who were reassessed on average 9.6 years after surgery (76% follow-up rate). The Lysholm and Gillquist score improved in both groups after surgery and remained elevated but reached statistical significance only in ACI-P at T1 and T2. IKDC scores increased significantly at all postoperative evaluation time points in ACI-P. In MACI, IKDC scores showed a significant increase at T1 and T3 when compared with T0. In the majority of the patients (10/16; MACI, 5/9; ACI-P, 5/7) a complete defect filling was present at the final follow-up as shown by the MOCART score, and 1 patient in the ACI-P group displayed hypertrophy of the repair tissue, which represents 6% of the whole study group and 14.3% of the ACI-P group. Besides higher SF-36 vitality scores in ACI-P at T3, no significant differences were seen in clinical scores and MRI scores between the 2 methods at any time point. Revision rate was 33.3% in MACI and 28.6% in ACI-P at the last follow-up. CONCLUSION: Our long-term results suggest that first- and third-generation ACI methods are equally effective treatments for isolated full-thickness cartilage defects of the knee. With the number of participants available, no significant difference was noted between MACI and ACI-P at any time point. Interpretation of our data has to be performed with caution due to the small sample size, which was further limited by a loss to follow-up of 24%.

Prognostic value of chondral defects on the outcome after arthroscopic treatment of acetabular labral tears.

Pathology of the acetabular labrum plays an increasing role in the treatment of hip pain. Hip arthroscopy has proven its clinical value as a useful procedure for successful treatment of labral tears. Until today, only a few studies have investigated the influence of articular cartilage defects on the clinical outcome of partial arthroscopic labrum resection in a larger patient population. We prospectively evaluated patients with an intraoperatively proven labral lesion/tear without any radiological and arthroscopical sign of a concomitant bony femoroacetabular impingement or hip dysplasia for a minimum postoperative follow-up of 2 years. Cartilage defects were classified according to Outerbridge and divided into two subgroups: Outerbridge < or = 1 and Outerbridge > or = 2, respectively. To evaluate combined results, various established scoring systems (visual analogue scale, modified Harris Hip Score, Larson Hip Score) were used. Out of 54 originally enrolled patients, 50 individuals (29 female, 21 male) with a median age of 33 years (range 15-49) were available for follow-up after a mean of 34 (range 24-48) months. At follow-up, the total study population experienced significant improvement in pain and in the combined evaluation scales (Larson Hip Score/MHHS). When patients were categorized into two subgroups, either with intraoperatively present or absent articular cartilage defects, our data indicated that subjects with no degenerative changes of the articular cartilage surface significantly improved in the applied clinically scoring systems. In contrast, in patients with an articular cartilage lesion during hip arthroscopy score values had a tendency to be unimproved or even deteriorated at follow-up. Regression analysis revealed a significant negative correlation between postoperative outcome and the grading of the coexistent articular cartilage defect. On the basis of our investigation, we conclude that partial arthroscopic resection of a torn labrum without attending bone deformity (dysplasia or femoroacetabular impingement) can reveal good and satisfied results. Depending on the extent of a coexisting articular cartilage defect subjective clinical results are compromised.

Effectiveness of a home-based re-injury prevention program on motor control, return to sport and recurrence rates after anterior cruciate ligament reconstruction: study protocol for a multicenter, single-blind, randomized controlled trial (PReP).

BACKGROUND: Although anterior cruciate ligament (ACL) tear-prevention programs may be effective in the (secondary) prevention of a subsequent ACL injury, little is known, yet, on their effectiveness and feasibility. This study assesses the effects and implementation capacity of a secondary preventive motor-control training (the Stop-X program) after ACL reconstruction. METHODS AND DESIGN: A multicenter, single-blind, randomized controlled, prospective, superiority, two-arm design is adopted. Subsequent patients (18-35 years) with primary arthroscopic unilateral ACL reconstruction with autologous hamstring graft are enrolled. Postoperative guideline rehabilitation plus Classic follow-up treatment and guideline rehabilitation plus the Stop-X intervention will be compared. The onset of the Stop-X program as part of the postoperative follow-up treatment is individualized and function based. The participants must be released for the training components. The endpoint is the unrestricted return to sport (RTS) decision. Before (where applicable) reconstruction and after the clearance for the intervention (aimed at 4-8 months post surgery) until the unrestricted RTS decision (but at least until 12 months post surgery), all outcomes will be assessed once a month. Each participant is consequently measured at least five times to a maximum of 12 times. Twelve, 18 and 24 months after the surgery, follow-up-measurements and recurrence monitoring will follow. The primary outcome assessement (normalized knee-separation distance at the Drop Jump Screening Test (DJST)) is followed by the functional secondary outcomes assessements. The latter consist of quality assessments during simple (combined) balance side, balance front and single-leg hops for distance. All hop/jump tests are self-administered and filmed from the frontal view (3-m distance). All videos are transferred using safe big content transfer and subsequently (and blinded) expertly video-rated. Secondary outcomes are questionnaires on patient-reported knee function, kinesiophobia, RTS after ACL injury and training/therapy volume (frequency - intensity - type and time). All questionnaires are completed online using the participants' pseudonym only. Group allocation is executed randomly. The training intervention (Stop-X arm) consists of self-administered home-based exercises. The exercises are step-wise graduated and follow wound healing and functional restoration criteria. The training frequency for both arms is scheduled to be three times per week, each time for a 30 min duration. The program follows current (secondary) prevention guidelines. Repeated measurements gain-score analyses using analyses of (co-)variance are performed for all outcomes. TRIAL REGISTRATION: German Clinical Trials Register, identification number DRKS00015313 . Registered on 1 October 2018.

Strength Training Effects on Muscular Regeneration after ACL Reconstruction.

PURPOSE: Protracted quadriceps muscle atrophy is observed after anterior cruciate ligament reconstruction (ACL-R). The aim of this study was to assess if quadriceps strength training with eccentric overload (CON/ECC) is more efficient to induce muscle regeneration after ACL-R than conventional concentric/eccentric (CON/ECC) strength training. METHODS: Biopsies from the vastus lateralis muscle were obtained from 37 recreational athletes after 12 wk of regular rehabilitation after ACL-R and again after 12 wk with twice a week of either conventional CON/ECC (n = 16) or CON/ECC (n = 21) one-legged supervised leg-press training. Immunohistochemical analyses were used to determine satellite cell (SC) number (Pax7); activated SC number (Pax7/MyoD); fibers expressing myosin heavy-chain (MHC) I and II, MHC neonatal, and fiber cross-sectional area. Magnetic resonance imaging was performed to measure quadriceps cross-sectional area and isokinetic testing for the measurement of quadriceps strength. RESULTS: CON/ECC induced a significantly (P = 0.002) greater increase in quadriceps cross-sectional area than did CON/ECC. There also was a significant increase in the fiber cross-sectional areas of all fiber types and in quadriceps strength, but without significant difference between training groups. Only CON/ECC training led to a significant (P < 0.05) increase in percent type I fibers. After training, the number of MHC I/MHCneo fibers was significantly (P < 0.05) greater in the CON/ECC than after in the CON/ECC group. The proportion of hybrid fibers tended to decrease in both groups; percent type II fibers, SC number, and activated SC number remained unchanged. CONCLUSIONS: CON/ECC leads to significantly greater muscle hypertrophy compared with CON/ECC, but without the hypothesized enhancing effect on SC activation. At the same time, CON/ECC+ induces a less favorable slower muscle phenotype for strong and fast movements.

The impact of pain spread on the outcome of multidisciplinary therapy in patients with chronic musculoskeletal pain - a prospective clinical study in 389 patients.

BACKGROUND: Musculoskeletal pain represents a continuous process ranging from single-site to multiple-site pain, with an increase in pain sites accompanied by an increasing risk of chronification and the development of further comorbidities. Within this context, the impact of pain spread on therapy outcome is still unknown. AIMS: This prospective clinical study aimed to evaluate whether and to what extent patients with pain at multiple sites would also benefit from multidisciplinary therapy or whether therapy success is limited by pain spread. METHODS: Patients' characteristics were assessed, including socio-demographic variables, occupational and workplace characteristics, pain intensity and dimensions of pain, psychological aspects and functional back capacity, as well as the generic health status. Data were prospectively collected at day 1 (baseline) and at 6-month follow-up from a sample of 389 patients undergoing multidisciplinary treatment. Patients were distributed into three groups based on the number of pain sites (single-site, dual-site and multiple-site) and the outcome parameters were compared. RESULTS: All three groups improved significantly from baseline to the 6-month follow-up. Compared to patients with multiple-site pain, patients with single-site and dual-site pain displayed significantly better outcome on almost all measures. Only the subcategory mental health of the SF-36 did not show any statistically significant differences among the three groups. CONCLUSIONS: Our results display that patients with two or more pain sites also improve significantly in the outcome measures. Therefore, treatment should be offered independent of the extent of pain spread. However, therapy is significantly less successful in patients with pain at multiple sites.