Sport after Knee Replacement Surgery - a Review of Sport Habits and Key Surgical Aspects. / Sport mit Knieprothese ­ Wieviel Sport ist möglich und was gilt es zu beachten ?

As an increasing number of younger patients are undergoing total knee replacement (TKR) surgery, many wish to participate in sport, but still expect that the implant will survive for a extended period. Most of the current literature shows that patients predominantly participate in low impact activities, both before and after surgery. A few studies show that with appropriate previous experience, high-impact sports are possible and might not result in increased implant failure rates. These include a decrease in point loads on the polyethylene by using more conform bearing surfaces, avoidance of varus component alignment to minimise stresses at the implant bone interface and avoiding patella resurfacing to facilitate activities in deep knee flexion.A TKR is no longer an absolute contraindication for higher impact activities such as golf, tennis and ski. What is more important than implant specific factors seem to be patient specific factors, including preoperative activity level, and preoperative sport skills.The current review paper reports on the current sport habits of TKR patients, analyses biomechanical loads on the knee during different sport activities and reports on implant selection and technical considerations for the active patient undergoing TKR.

Midterm results of the Birmingham hip resurfacing: a single-surgeon series.

INTRODUCTION: Birmingham hip resurfacing (BHR) is readily used as alternative to total hip replacement in younger patients. The current study aims to compare outcomes in terms of adverse local tissue reactions (ALTR), elevated metal ion levels and survival rates between low-risk (femoral component size ≥ 48 mm) and high-risk (femoral component size < 48 mm) BHR patients at a minimum 5-year follow-up (FU). MATERIALS AND METHODS: We report the minimum 5-year, single surgeon outcome results of 183 BHRs, performed between 2007 and 2012. 154 patients, 18 women (20 hips) and 136 men (163 hips) were included in the study. Patients were grouped in 149 low-risk cases (femoral component size ≥ 48 mm) and in 34 high-risk cases (18 female/12 male) patients with a femoral head size < 48 mm). RESULTS: At a minimum of 5-years FU time, 91% of the patients were available for FU. The overall survival rate was 91.8%. There were five revisions (survival rate 96.6%) in the low-risk group and ten revisions (survival rate 70.6%) in the high-risk group. In the low-risk group, six patients (6.5%) showed elevated metal ion levels (> 7 µg/l), compared to five patients (20.8%) in the high risk-group (p = 0.03). CONCLUSION: Including the surgeon's initial learning curve, the BHR shows very good mid-term survival rates in the low-risk group but should, as previously demonstrated, not be considered for patients with less than 48 mm femoral head size. LEVEL OF EVIDENCE: Level III: retrospective cohort study.

The role of synovial fluid aspiration in shoulder joint infections.

BACKGROUND: Joint aspiration with analysis of synovial fluid white blood cell count (WBC) and microbiological culture is a widely established aspect in the diagnosis of shoulder joint infections (SJI). In case of a two stage revision for SJI, joint aspiration before re-/implantation of a total shoulder arthroplasty (TSA) was used to rule out persistent infection for years but its value is under debate. Shoulder specific data on all aspects is rare. The current study aims to answer the following research questions: Does joint aspiration have an insufficient predictive value in the diagnosis of SJI in (1) initial workup and (2) before definite arthroplasty with polymethylmethacrylate (PMMA)-Spacer in place? METHODS: This retrospective evaluation investigates 35 patients that were treated for SJI with a two staged implantation of a TSA after debridement and implantation of an PMMA-Spacer. Joint aspirations were performed preoperatively (PA) and before re-/implantation of the prosthesis while spacer was in place (interstage aspiration, IA). Samples were taken for microbiological culture and analysis of WBC. Sensitivity and specificity were calculated with reference to intraoperative microbiological samples. Receiver Operating Characteristic (ROC), Area-Under-Curve analysis (AUC) and calculation of the Youden index were performed to find optimum cut-off for WBC. RESULTS: The sensitivity of microbiological cultures from PA was 58.3% and the specificity was 88.9%. The mean WBC was 27,800 leucocytes/mm3 (range 400-96,300). The maximum Youden index (0.857) was a cut-off of 2600 leucocytes/mm3 with a sensitivity of 85.7% and a specificity of 100.0%. The sensitivity and specificity of IA were 0.0% and 88.5%, respectively. CONCLUSIONS: Preoperative aspiration is likely to miss Cutibacteria spp. and CoNS and cannot rule out infection for sure. However, we recommend it for its advantages of targeted antibiotic therapy in case of germ identification. Empiric antibiotic therapy should cover Cutibacteria and CoNS even if aspiration showed negative microbiological cultures. In contrast, the diagnostic value of interstage aspiration does not qualify for its routine use.

[Clavicle stress fracture following reverse shoulder arthroplasty]. / Insuffizienzfraktur der Klavikula nach Implantation einer inversen Schulterendoprothese.

We present a rare case of clavicle fracture following reverse shoulder arthroplasty (RSA). This complication may be caused by the higher tension of the deltoid muscle after RSA, similarly to stress fractures of the acromion. Associated bone disease, i.e. osteoporosis, may contribute. In the few case reports available, the affected patients showed significant functional impairments. In the current case, the fracture was addressed with plate fixation. Despite good intraoperative results, osteosynthesis failure with secondary dislocation of the fracture occurred.

A standardized soft tissue release technique to lower the risk of greater trochanteric fractures for the anterior approach in total hip arthroplasty.

INTRODUCTION: The direct anterior approach (DAA) is suggested to accelerate postoperative recovery and decrease the dislocation risk after primary total hip arthroplasty (THA). However, exposure of the femur can be challenging. Insufficient exposure increases the risk for intraoperative femoral fracture. MATERIALS AND METHODS: Of 435 consecutive anterior THA, the first 102 consecutive THA in 94 patients were treated with an external rotator tendon "release-on-demand" (RoD). The following 311 consecutive patients (333 THA) underwent routine release of the conjoint tendon (CTR) of its bony insertion on the greater trochanter only. Retrospective analysis recorded trochanteric fractures, intraoperative calcar fractures, postoperative periprosthetic fractures, stem subsidence, ossifications, and dislocations. RESULTS: Three (2.9%) fractures of the greater trochanter were recorded in the RoD group, but no (0.0%) fractures occurred in the CTR group (p = 0.002). There was no significant difference in the occurrence of intraoperative calcar fractures (0% (RoD) vs. 1.2% (CTR), p = 0.267), postoperative periprosthetic fractures (0% (RoD) vs. 0.3% (CTR), p = 0.560), stem subsidence (2.0% (RoD) vs. 1.2% (CTR), p = 0.565) or ossifications (2.9% (RoD) vs. 1.6% (CTR), p = 0.344) between these groups. There were no dislocations within a minimum 12 months follow-up period. CONCLUSION: The routine release of the conjoined tendon (CTR group) decreases the shear forces on the tip of the greater trochanter during DAA THA and eliminates the risk of greater trochanter fractures. The routine release of the conjoined tendon did not increase the risk of postoperative dislocations.

Anterior hip replacement: lower dislocation rates despite less restrictions?

INTRODUCTION: Dislocation in Total hip arthroplasty (THA) is a common postoperative complication and reason for revision surgery. The direct anterior approach has become more popular over the last decade. The purpose of this study was to compare postoperative dislocation rates of the direct anterior and the posterior approach at a one-year follow-up. MATERIAL AND METHODS: 797 consecutive hips operated through a posterior approach [698 patients (307 male, 391 female)] between 2009 and 2012, were compared to 690 selected THA [610 patients (423 female, 187 male)] operated since 2012. Anterior hip replacement surgery was primarily indicated for patients demanding increased flexibility after surgery (Yoga) or were considered a higher risk for dislocation. RESULTS: During a one-year follow-up there were eight dislocations out of 797 THA (1%) in the posterior group and none in the 690 THA (0%) in the anterior group (p-value of 0.008). Average time to dislocation was 7.5 weeks in the posterior group. Five of eight patients with dislocations needed revision surgery due to persistent instability. CONCLUSION: Even in a higher-risk patient population, the direct anterior approach showed a lower dislocation rate compared to the posterior approach in the first year after surgery.

Diagnosis of Chronic Infection at Total Hip Arthroplasty Revision Is a Question of Definition.

PURPOSE: Contradicting definitions of periprosthetic joint infection (PJI) are in use. Joint aspiration is performed before total hip arthroplasty (THA) revision. This study investigated the influence of PJI definition on PJI prevalence at THA revision. Test quality of prerevision aspiration was evaluated for the different PJI definitions. METHODS: 256 THA revisions were retrospectively classified to be infected or not infected. Classification was performed according to the 4 different definitions proposed by the Musculoskeletal Infection Society (MSIS), the Infectious Diseases Society of America (IDSA), the International Consensus Meeting (ICM), and the European Bone and Joint Infection Society (EBJIS). Only chronic PJIs were included. RESULTS: PJI prevalence at revision significantly correlated with the applied PJI definition (p = 0.01, Cramer's V = 0.093). PJI prevalence was 20.7% for the MSIS, 25.4% for the ICM, 28.1% for the IDSA, and 32.0% for the EBJIS definition. For synovial fluid white blood cell count, the best ROC-AUC for predicting PJI was 0.953 in combination with the MSIS definition. CONCLUSION: PJI definition significantly influences the rate of diagnosed PJIs at THA revision. Synovial fluid white blood cell count is a reliable means to rule out PJI. In cases with a borderline high synovial white blood cell count before THA revision as the only sign of chronic PJI, an extended diagnostic work-up should be considered.

Less than 9.5-mm coracohumeral distance on axial magnetic resonance imaging scans predicts for subscapularis tear.

BACKGROUND: Diagnosis of subscapularis (SSC) tendon lesions on magnetic resonance imaging (MRI) can be challenging. A small coracohumeral distance (CHD) has been associated with SSC tears. This study was designed to define a specific threshold value for CHD to predict SSC tears on axial MRI scans. METHODS: This retrospective study included 172 shoulders of 168 patients who underwent arthroscopic surgery for rotator cuff tear or glenohumeral instability. Diagnostic arthroscopy confirmed an SSC tear in 62 cases (36.0%, test group a), rotator cuff tear tears other than SSC in 71 cases (41.3%, control group b) and glenohumeral instability without any rotator cuff tear in 39 cases (22.7%, zero-sample group c). All patients had a preoperative MRI of the shoulder (1.5T or 3T). Minimum CHD was measured on axial fat-suppressed proton density-, T2-, or T1-weigthed sequences. Receiver operating characteristics analysis was used to determine the threshold value for CHD, and sensitivity and specificity were calculated. RESULTS: CHD measurement had a good interobserver reliability (Intraclass correlation coefficient 0.799). Mean CHD was highly significantly (P < .001) less for test group a (mean 7.3 mm, standard deviation ± 2.2) compared with control group b (mean 11.1 mm, standard deviation ± 2.3) or zero-sample group c (mean 13.6 mm, standard deviation ± 2.9). A threshold value of CHD <9.5 mm had a sensitivity of 83.6% and a specificity of 83.9% to predict SSC tears. CONCLUSION: A CHD <9.5 mm on MRI is predictive of SSC lesions and a valuable tool to diagnose SSC tears.

Can a simple iPad app improve C-arm based component position in anterior THA?

INTRODUCTION: Correct acetabular component positioning improves hip biomechanics, impingement free range of motion and may lead to a reduced risk of postoperative dislocation. The C-arm is a simple and cost-effective tool for THA in a supine position, however, evaluation of the images can be challenging due to parallax. The current study aimed to investigate whether a software app-based measurement technique can control acetabular component position and leg length in anterior THA. MATERIALS AND METHODS: Ninety-three patients with end-stage osteoarthritis aged 65.2 ± 9.6 years (range 30-86 years) were included in this prospective study. All patients underwent direct anterior THA using a Hana orthopedic surgery table. C-arm imaging and an iPad software app were used to determine intraoperative acetabular anteversion, inclination and leg length discrepancy. The app provides a measuring tool that is applied to intraoperative c-arm images. The intraoperative measurements were compared to the measurements of standard postoperative AP-pelvis radiographs. RESULTS: Intraoperative software app-based anteversion measurements averaged 20.5° (range 16.0° to 24.0°) compared to 20.9° (range 14.7° to 25.6°) postoperatively. Mean intraoperative inclination was 40.5° (range 35° to 48°) compared to postoperative 40.7° (range 35° to 49°). Mean intraoperative leg length discrepancy was 0.9 mm (range - 4-5 mm) compared to postoperative 0.6 mm (range - 5-6 mm). A strong Pearson's correlation was observed between the intraoperative and postoperative measurements for anteversion (r = .701; P < .0001), inclination (r = .816; P < .0001) and leg length discrepancy (r = .542; P < .0001). CONCLUSIONS: The software app used in the current study allowed for a simple and accurate measurement of intraoperative cup position and leg length in direct anterior THA.

Severity of valgus knee osteoarthritis has no effect on clinical outcomes after total knee arthroplasty.

INTRODUCTION: Advanced valgus osteoarthritis (OA) is one of the most challenging indications for total knee arthroplasty (TKA). There is no information in the literature about the optimal timing of surgery. The current study investigates the impact of the preoperative deformity and degree of arthritis on postoperative outcome after TKA. MATERIAL AND METHODS: The study evaluated 133 knees in 107 patients with valgus OA that failed nonoperative treatment with a minimum 2-year follow-up. Mechanical alignment, Kellgren and Lawrence (K/L) score, and minimal joint space width (minJSW) were measured on AP- and hip-to-ankle radiographs. All knees had advanced OA (i.e., K/L grades 3 or 4 and less than 50% minJSW). Pre- and postoperative WOMAC, VR-12, UCLA, VAS, ROM were recorded. RESULTS: There was no difference in clinical outcome (WOMAC, UCLA, VR-12, VAS or ROM) between patients with different degrees of valgus deformities (< 5.0 deg., 5.0-9.9 deg., 10.0-14.9 deg., ≥ 15.0 deg.). There was also no correlation between K/L score or minimal joint space width and any of the outcome parameters. CONCLUSIONS: The degree of valgus deformity and the grade of osteoarthritis do not predict the outcome of TKA in patients with valgus OA. Since the risk of complication and the need for implant constraint increases with increasing deformity and instability of the knee, surgery appears to be justified in patients with advanced OA that failed nonoperative treatment, regardless of the degree of deformity.

No functional differences in anatomic reconstruction using a one- versus a two-point fixation for distal biceps tendon rupture through a single-incision anterior approach: A prospective randomized trial.

BACKGROUND: The distal biceps brachii tendon rupture is a rare injury of the musculoskeletal system. Multiple surgical techniques have been described for distal biceps brachii tendon repairs including suture anchors. OBJECTIVE: The aim of this study was to evaluate the outcome of anatomical distal biceps tendon refixation using either one or two suture anchors for reattachment and to determine whether there are significant clinically important differences on the number of anchors used for refixation. METHODS: A monocentric, randomized controlled trial was conducted, including 16 male patients with a mean age of 47.4 years (range, 31.0 to 58.0) in Group 1 (two suture anchors for refixation) and 15 male patients with a mean age of 47.4 (range, 35.0 to 59.0) in Group 2 (one suture anchor for refixation). All surgeries were performed through an anterior approach. The outcome was assessed using the Oxford Elbow Score (OES), the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Andrews Carson Score (ACS) and by isokinetic strength measurement for the elbow flexion after six, twelve, 24 and 48 weeks. Radiographic controls were performed after 24 and 48 weeks. RESULTS: No significant differences between both groups were evident at any point during the follow-up period. A continuous improvement in outcome for both groups could be detected, reaching an OES: 46.3 (39.0 to 48.0) vs. 45.5 (30.0 to 48.0), MEPS: 98.0 (85.0 to 100.0) vs. 99.0 (85.0 to 100.0), DASH: 3.1 (0.0 to 16.7) vs. 2.9 (0.0 to 26.7), ACS: 197.0 (175.0 to 200.0) vs. 197.7.

Defining a Synovial Fluid White Blood Cell Count Threshold to Predict Periprosthetic Infection after Shoulder Arthroplasty.

BACKGROUND: The diagnosis of periprosthetic shoulder infection (PSI) requires a thorough diagnostic workup. Synovial fluid aspiration has been proven to be a reliable tool in the diagnosis of joint infections of the lower extremity, but shoulder specific data is limited. This study defines a threshold for synovial fluid white blood cell count (WBC) and assesses the reliability of microbiological cultures. METHODS: Retrospective study of preoperative and intraoperative fluid aspiration of 31 patients who underwent a revision of a shoulder arthroplasty (15 with PSI defined by IDSA criteria, 16 without infection). The threshold for WBC was calculated by ROC/AUC analysis. RESULTS: WBC was significantly higher in patients with PSI than in other patients. A threshold of 2800 leucocytes/mm3 showed a sensitivity of 87% and a specificity of 88% (AUROC 0.92). Microbiological cultures showed a sensitivity of 76% and a specificity of 100%. CONCLUSIONS: A threshold of 2800 leucocytes/mm3 in synovial fluid can be recommended to predict PSI. Microbiological culture has an excellent specificity and allows for targeted antibiotic therapy. Joint aspiration presents an important pillar to diagnose PSI.

Infection control and outcome of staged reverse shoulder arthroplasty for the management of shoulder infections.

BACKGROUND: The treatment of septic arthritis, caused by either hematogenous seeding, injections, or surgery, can be challenging. Staged reverse shoulder arthroplasty (RSA) with temporary implantation of an antibiotic-loaded spacer is widely accepted but still discussed controversially. This study investigated the shoulder-specific bacterial spectrum, infection control rate, functional outcome, and infection-free survival rate after staged RSA in the mid- to long-term follow-up. It was hypothesized that staged RSA would show a high infection-free survival rate. METHODS: A total of 39 patients treated with staged RSA for primary septic arthritis (n = 8), secondary infection (n = 8), or periprosthetic infection (n = 23) were retrospectively included. The infection control rate was calculated based on cultures taken intraoperatively at spacer removal and RSA implantation. Infection-free survival was defined as no revision due to infection. The minimum follow-up period for functional outcome assessment was 2 years (n = 14; mean, 76 months; range, 31-128 months). RESULTS: Cutibacterium (26%) and coagulase-negative staphylococci (23%) were the predominant pathogens. The infection control rate was 90%. The cumulative infection-free survival rate was 91% after 128 months. Follow-up examinations showed a mean Constant score of 48 (range, 7-85), a mean QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score of 40.0 (range, 11.4-93.3), and a mean pain score of 1.6 (range, 0-7). CONCLUSION: Staged RSA implantation was confirmed to be a reliable treatment option for primary, secondary, and periprosthetic infections of the shoulder. The infection control rate and infection-free survival rate are satisfactory. However, patients and surgeons must be aware of functional impairment even after successful treatment of infections.

Return to sports after hip resurfacing versus total hip arthroplasty: a mid-term case control study.

BACKGROUND: Hip resurfacing (HR) is an alternative to conventional total hip arthroplasty (THA) for the treatment of osteoarthritis (OA) in very active, young male patients. However, there is no study in the literature that has proven its benefits for high-impact sport over standard primary THA. The aim of the current study was to investigate the return to sport and function level of male patients after THA vs. HR. MATERIALS AND METHODS: This prospective study is based on a telephone questionnaire for general health and sports activities. 40 HRs were matched with 40 THAs based on preoperative University of California Arthroplasty Score (UCLA), BMI, age at time of surgery and age at follow-up. The mean follow-up period was 56 months (range 24-87 months). RESULTS: HR patients showed a significantly higher High-activity arthroplasty score (HAAS) (14.9 vs. 12.9, p < 0.001) and Lower extremity activity scale (LEAS) (15.9 vs. 14.1, p < 0.001) and reached significantly higher values in the Hip cycle score (HCS) (44.7 vs. 35.7 p = 0.037) and Impact score (IS) (40.9 vs. 29.6, p < 0.002) than THA patients. No significant differences were found in the HOOS function section (91.4 vs. 90.3, p = 0.803) and the Pain numeric rating scale (NRS)-11 (0.6 vs. 0.9 p = 0.169). Patients with HR had a slightly higher Harris hip score (HHS) (97.8 vs. 95.6, p = 0.015) CONCLUSION: The current study suggests that young male patients are able to engage in higher activity levels after HR compared to standard THA.

Clinical outcome of posterior-stabilized total knee arthroplasty using an increased flexion gap in patients with preoperative stiffness.

AIMS: To compare patients undergoing total knee arthroplasty (TKA) with ≤ 80° range of movement (ROM) operated with a 2 mm increase in the flexion gap with matched non-stiff patients with at least 100° of preoperative ROM and balanced flexion and extension gaps. METHODS: In a retrospective cohort study, 98 TKAs (91 patients) with a preoperative ROM of ≤ 80° were examined. Mean follow-up time was 53 months (24 to 112). All TKAs in stiff knees were performed with a 2 mm increased flexion gap. Data were compared to a matched control group of 98 TKAs (86 patients) with a mean follow-up of 43 months (24 to 89). Knees in the control group had a preoperative ROM of at least 100° and balanced flexion and extension gaps. In all stiff and non-stiff knees posterior stabilized (PS) TKAs with patellar resurfacing in combination with adequate soft tissue balancing were used. RESULTS: Overall mean ROM in stiff knees increased preoperatively from 67° (0° to 80°) to 114° postoperatively (65° to 135°) (p < 0.001). Mean knee flexion improved from 82° (0° to 110°) to 115° (65° to 135°) and mean flexion contracture decreased from 14° (0° to 50°) to 1° (0° to 10°) (p < 0.001). The mean Knee Society Score (KSS) improved from 34 (0 to 71) to 88 (38 to 100) (p < 0.001) and the KSS Functional Score from 43 (0 to 70) to 86 (0 to 100). Seven knees (7%) required manipulations under anaesthesia (MUA) and none of the knees had flexion instability. The mean overall ROM in the control group improved from 117° (100° to 140°) to 123° (100° to 130°) (p < 0.001). Mean knee flexion improved from 119° (100° to 140°) to 123° (100° to 130°) (p < 0.001) and mean flexion contracture decreased from 2° (0° to 15°) to 0° (0° to 5°) (p < 0.001). None of the knees in the control group had flexion instability or required MUA. The mean KSS Knee Score improved from 48 (0 to 80) to 94 (79 to 100) (p < 0.001) and the KSS Functional Score from 52 (5 to 100) to 95 (60 to 100) (p < 0.001). Mean improvement in ROM (p < 0.001) and KSS Knee Score (p = 0.017) were greater in knees with preoperative stiffness compared with the control group, but the KSS Functional Score improvement was comparable (p = 0.885). CONCLUSION: TKA with a 2 mm increased flexion gap provided a significant improvement of ROM in knees with preoperative stiffness. While the improvement in ROM was greater, the absolute postoperative ROM was less than in matched non-stiff knees. PS TKA with patellar resurfacing and a 2 mm increased flexion gap, in combination with adequate soft tissue balancing, provides excellent ROM and knee function when stiffness of the knee had been present preoperatively. Cite this article: Bone Joint J 2020;102-B(4):426-433.

No functional differences in anatomic reconstruction with one vs. two suture anchors after non-simultaneous bilateral distal biceps brachii tendon rupture: a case report and review of the literature.

BACKGROUND: Surgical reattachment of the tendon is still the gold standard for ruptures of the distal biceps brachii tendon. Several fixation techniques have been described in the literature, with suture anchors being one of the most common fixation techniques. Currently, there is no data available on how many anchors are required for a safe and stable refixation. In this case report clinical data of a patient with non-simultaneous bilateral distal biceps tendon ruptures treated with a different number of suture anchors for each side (one vs. two) are demonstrated. CASE PRESENTATION: A 47-year-old factory worker suffered a rupture of the distal biceps tendon on both arms following two different occasions. The left side was fixed using a single suture anchor, while refixation on the right side was performed with two anchors. The patient was prospectively followed for one year. Functional outcome was assessed using the Andrews Carson Score (ACS), the Oxford Elbow Score (OES), and the Disabilities of Arm, Shoulder and Hand (DASH) Score after six, twelve, 24 and 48 weeks. Furthermore, an isokinetic strength measurement for flexion strength was performed after 24 and 48 weeks. After 48 weeks the patient presented with excellent functional outcome scores and no follow-up complications. During the follow-up period, no differences in the functional scores nor in the isokinetic flexion strength measurement could be detected. Furthermore, no radiological complications (like heterotopic ossifications) could be detected in the postoperative radiographs after one year. CONCLUSIONS: Anatomic reattachment of the distal biceps tendon is a successful operative treatment option for distal biceps tendon ruptures. Suture anchor fixation remains one of the most common techniques, as it allows fast surgery and provides good results with respect to range of motion (ROM) and functional scoring according to the current literature. However, the number of anchors required for a stable fixation remains unclear. As indicated by our presented case, we hypothesize, that there are no significant differences between a one-point or a two-point fixation. In the presented case report, no intraindividual differences between the usage of one versus two suture anchors were evident in the short-term follow-up.

The influence of femoral and tibial bony anatomy on valgus OA of the knee.

PURPOSE: Approximately 10% of all patients that require a total knee arthroplasty present with valgus osteoarthritis (OA) of the knee. Valgus OA goes along with posterolateral bone loss and lateral soft tissue tightness. The role of malalignment on the development of OA is not fully understood. The current study investigates whether the femoral offset (FO), femoral mechanical-anatomical (FMA) angle, anatomical lateral distal femur angle (aLDFA), mechanical lateral distal femur angle (mLDFA), medial proximal femur angle (MPFA), medial proximal tibia angle (MPTA) or lateral distal tibia angle (LDTA) differ in patients with valgus OA of the knee. METHODS: FO, FMA angle, aLDFA, mLDFA, MPFA, MPTA and LDTA were assessed and compared between 100 consecutive knees with minimal valgus OA (50 male, 50 female) and 100 consecutive knees with minimal varus OA (50 male, 50 female). RESULTS: FO was significantly higher in males with valgus OA (p = 0.002) and females with varus OA (p = 0.01). The observed values for the FMA angle were significantly higher in males with valgus OA (p = 0.002) and females with varus OA (p = 0.041). The aLDFA and mLDFA were significantly smaller in all patients with valgus OA (p < 0.001). No differences between the varus and valgus groups were detected regarding MPFA (males: p = 0.052; females: p = 0.719). Tibial measurements showed significantly higher values for the MPTA (p < 0.001) in both valgus groups and no difference for LDTA (men: p = 0.139; women: p = 0.196). CONCLUSION: Bony alterations in the femoral anatomy seem to be more important than in the tibial anatomy. While in male patients with valgus OA, the main anatomic variation is the hypoplasia of the lateral femoral condyle, in females both decreased femoral offset of the hip as well as hypoplasia of the lateral condyle are present. LEVEL OF EVIDENCE: III.

Five Questions to Identify Patients With Osteoarthritis of the Knee.

BACKGROUND: To treat the increasing number of patients with osteoarthritis (OA) of the knee, high-volume institutions rely on central referral services as first contact point. Depending on the grading of arthritis, patients will be referred to a nonoperative or operative care provider. The present study reports on a simple 5-step questionnaire to identify patients with OA (Kellgren/Lawrence [KL] grade ≥2) of the knee to improve efficiency of referrals. METHODS: We included 998 patients who contacted the physician referral service at the author's institution complaining of knee pain and divided them into 2 groups. The study group included patients with an appointment and consisted of 646 patients (345 women [53.4%] and 301 men [46.6%]). X-rays of the knee were graded according to the KL classification system. The control group of patients who did not make an appointment consisted of 352 patients (187 women [53.1%] and 165 men [46.9%]). These patients were contacted to evaluate whether they had been diagnosed with OA of the knee since their initial call, to assure that the study group was not exposed to a selection bias. RESULTS: Logistic regression revealed 5 questions as significant predictors for OA of the knee (KL grade ≥2). When combining both groups, an 86.9% sensitivity, a 73.3% specificity, and an 84.3% overall accuracy were reached, when patients answered 3 or more questions positively. CONCLUSION: The present study revealed a simple 5-step questionnaire to identify patients with OA of the knee. Implementation of the questionnaire has the potential to improve the accuracy of referral processes and streamline organization before the first appointment.

[Indications and techniques of arthroscopic anterior and lateral acromioplasty]. / Aktuelle Indikationen und Techniken der arthroskopischen anterioren und lateralen Akromioplastik.

OBJECTIVE: Arthroscopic anterior acromioplasty (AAAP) for treatment of symptomatic subacromial spur. Arthroscopic lateral acromioplasty (ALAP) to reduce a pathological critical shoulder angle (CSA) and prevent rotator cuff re-tear after reconstruction. INDICATIONS: AAAP is indicated for acromial impingement due to an anterolateral acromial spur with or without bursa-sided rotator cuff lesion. ALAP is indicated concomitant to arthroscopic rotator cuff repair if the CSA is pathologically increased. RELATIVE CONTRAINDICATIONS: Irreparable rotator cuff tear with acetabularization of the acromion due to anterosuperior escape of the humeral head or symptomatic os acromiale can contraindicate for AAAP. Dehiscence of the origin of the deltoid muscle or symptomatic os acromiale can contraindicate for ALAP. SURGICAL TECHNIQUE: To preform AAAP, arthroscopic subacromial decompression is followed by anterolateral resection of an acromion spur or ossification of the coracoacromial ligament. To perform ALAP, arthroscopic subacromial decompression and reconstruction of a rotator cuff-tear is followed by reduction of a pathologically increased CSA by resection of the lateral edge of the acromion. POSTOPERATIVE MANAGEMENT: After isolated AAAP, physiotherapy can be performed without restriction. After AAAP or ALAP combined with rotator cuff repair, immobilization in a brace is recommended. The use of pain medication should be standardized and adapted to individual pain levels.