Pathogenesis and Diagnosis of Proximal Hamstring Tendinopathies.

The proximal hamstring complex is a highly vulnerable area that is especially prone to injury. Proximal hamstring tendinopathies (PHTs) remain challenging in diagnosis, treatment, rehabilitation, and prevention due to a large variety of different injuries, slow healing response, persistent symptoms, and functional impairments. PHTs are often misdiagnosed or underdiagnosed, leading to delayed treatment and therapy failure. In addition, many athletes are at a high risk of PHT recurrence, a leading cause of prolonged rehabilitation and impaired individual performance. Until now, there have been no clear criteria for the diagnosis and classification of PHT. Tendinopathies can be graded based on their symptoms and onset. Additionally, radiological characteristics exist that describe the severity of tendinopathies. The diagnosis usually includes a battery of pain provocation tests, functional tests, and imaging to ensure a proper classification. Understanding the specific tasks in the pathogenesis and diagnostic process of PHT requires knowledge of functional anatomy, injury pattern and pathophysiological mechanisms as well as examination and imaging techniques. This work provides a structured overview of the pathogenesis and diagnostic work-up of PHT, emphasizing structured examination and imaging to enable a reliable diagnosis and rapid treatment decisions.

Patient response to osteotomy around the knee joint at one year post-operation-fulfilment of expectations and current health status.

INTRODUCTION: The aim of this study was to investigate patient satisfaction and fulfilment of expectations after osteotomy around the knee at one year postoperatively, using patient-related outcome measures. MATERIALS AND METHODS: From the initial sample of 264 patients, a total of 132 patients (age 48y ± 11) were enrolled in this prospective study (response rate 49.3%). Data were collected using the Hospital For Special Surgery-Knee Surgery Expectations Survey (HFSS-KSES), items for satisfaction and the Knee injury and Osteoarthritis Outcome Score (KOOS) measures. At one year postoperative follow-up, an individualized questionnaire asked whether the specific person-related expectations had been fulfilled. RESULTS: Satisfaction was high with 83.2% of all participants at one year after surgery. A total of 78% of patients stated they would decide to do the surgery again. This decision was significantly associated with satisfaction, younger age and better KOOS scores scales before surgery for pain, activity and sports. We found high correlations between satisfaction and fulfilment of expectations for the HFES-KSES. Fulfilment of expectations one year after surgery was significantly associated with significant improvements in KOOS scales at one year post-operation. Expectations (1) "to get the knee back to normal status", (2) "improve ability to squat", (3) "improve ability to run", (4) "improve ability to kneel" had been fulfilled worst. A multiple linear regression model for satisfaction had an R2 = 0.797 of the variance. The most influential was the variable fulfilment of "maintain health" that had 70.7% of variance. CONCLUSIONS: The fulfilled expectation concerning an improvement of the ability to maintain health was the most influential parameter for satisfaction at one year post-osteotomy. Patients with better health status of the knee and younger age rated the surgery to be more positive and were also more likely to do the surgery again. This provides an indication for an earlier intervention, before the knee and overall health status becomes more detrimental. LEVEL OF EVIDENCE: Level II (Therapeutic study).

The lack of retropatellar resurfacing at index surgery is significantly associated with failure in patients following patellofemoral inlay arthroplasty: a multi-center study of more than 260 patients.

PURPOSE: To evaluate the clinical outcomes of patients with a minimum 2-year follow-up following contemporary patellofemoral inlay arthroplasty (PFIA) and to identify potential risk factors for failure in a multi-center study. METHODS: All patients who underwent implantation of PFIA between 09/2009 and 11/2016 at 11 specialized orthopedic referral centers were enrolled in the study and were evaluated retrospectively at a minimum 2-year follow-up. Clinical outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Tegner Scale, the visual analogue scale (VAS) for pain, and subjective patient satisfaction. Pre- and perioperative risk factors were compared among failures and non-failures to determine potential risk factors. RESULTS: A total of 263 patients (85% follow-up rate) could be enrolled. The mean age at the time of index surgery was 49 ± 12 years with a mean postoperative follow-up of 45 ± 18 months. The overall failure rate was 11% (28 patients), of which 18% (5 patients) were patients with patella resurfacing at index surgery and 82% (23 patients) were patients without initial patella resurfacing. At final follow-up, 93% of the patients who did not fail were satisfied with the procedure with a mean transformed WOMAC Score of 84.5 ± 14.5 points, a mean KOOS Score of 73.3 ± 17.1 points, a mean Tegner Score of 3.4 ± 1.4 points and a mean VAS pain of 2.4 ± 2.0 points. An increased BMI was significantly correlated with a worse postoperative outcome. Concomitant procedures addressing patellofemoral instability or malalignment, the lack of patellofemoral resurfacing at the index surgery and a high BMI were significantly correlated with failure in our patient cohort. CONCLUSION: Patellofemoral inlay arthroplasty shows high patient satisfaction with good functional outcomes at short-term follow-up and thus can be considered a viable treatment option in young patients suffering from isolated patellofemoral arthritis. Patellar resurfacing at index surgery is recommended to decrease the risk of failure. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Arthroscopic lateral retinacular release improves patello-femoral and femoro-tibial kinematics in patients with isolated lateral retinacular tightness.

PURPOSE: Arthroscopic lateral retinacular release (LRR) has long been considered the gold standard for the treatment for anterior knee pain caused by lateral retinacular tightness (LRT). However, one-third of patients experience continuous pain postoperatively, which is thought to be related to persistent maltracking of the patella and altered femoro-tibial kinematics. Therefore, the aim of the present study was to simultaneously assess femoro-tibial and patello-femoral kinematics and identify the influence of arthroscopic LRR. METHODS: Sixteen healthy volunteers and 12 patients with unilateral, isolated LRT were prospectively included. Open MRI scans with and without isometric quadriceps contraction were performed in 0°, 30° and 90° of knee flexion preoperatively and at 12 months after surgery. Patellar shift, tilt angle, patello-femoral contact area and magnitude of femoro-tibial rotation were calculated by digital image processing. RESULTS: Postoperatively, patellar shift was significantly reduced at 90° of knee flexion compared to preoperative values. The postoperative patellar tilt angle was found to be significantly smaller at 30° of knee flexion compared to that preoperatively. Isometric muscle contractions did not considerably influence patellar shift or tilt in either group. The patello-femoral contact area increased after LRR over the full range of motion (ROM), with significant changes at 0° and 90°. Regarding femoro-tibial kinematics, significantly increased femoral internal rotation at 0° was observed in the patient group preoperatively, whereas the magnitude of rotation at 90° of knee flexion was comparable to that of healthy individuals. The pathologically increased femoral internal rotation at 30° without muscular activity could be significantly decreased by LRR. With isometric quadriceps contraction no considerable improvement of femoral internal rotation could be achieved by LRR at 30° of knee flexion. CONCLUSIONS: Patello-femoral and femoro-tibial joint kinematics could be improved, making LRR a viable surgical option in carefully selected patients with isolated LRT. However, pathologically increased femoral internal rotation during early knee flexion remained unaffected by LRR and thus potentially accounts for persistent pain. LEVEL OF EVIDENCE: II.

Preserved Perspective Taking in Free Indirect Discourse in Autism Spectrum Disorder.

Perspective taking has been proposed to be impaired in persons with autism spectrum disorder (ASD), especially when implicit processing is required. In narrative texts, language perception and interpretation is fundamentally guided by taking the perspective of a narrator. We studied perspective taking in the linguistic domain of so-called Free Indirect Discourse (FID), during which certain text segments have to be interpreted as the thoughts or utterances of a protagonist without explicitly being marked as thought or speech representations of that protagonist (as in direct or indirect discourse). Crucially, the correct interpretation of text segments as FID depends on the ability to detect which of the protagonists "stands out" against the others and is therefore identifiable as implicit thinker or speaker. This so-called "prominence" status of a protagonist is based on linguistic properties (e.g., grammatical function, referential expression), in other words, the perspective is "hidden" and has to be inferred from the text material. In order to test whether this implicit perspective taking ability that is required for the interpretation of FID is preserved in persons with ASD, we presented short texts with three sentences to adults with and without ASD. In the last sentence, the perspective was switched either to the more or the less prominent of two protagonists. Participants were asked to rate the texts regarding their naturalness. Both diagnostic groups rated sentences with FID anchored to the less prominent protagonist as less natural than sentences with FID anchored to the more prominent protagonist. Our results that the high-level perspective taking ability in written language that is required for the interpretation of FID is well preserved in persons with ASD supports the conclusion that language skills are highly elaborated in ASD so that even the challenging attribution of utterances to protagonists is possible if they are only implicitly given. We discuss the implications in the context of claims of impaired perspective taking in ASD as well as with regard to the underlying processing of FID.

[The importance of ligament reconstruction with existing osteoarthritis]. / Stellenwert der Bandrekonstruktion bei bestehender Arthrose.

Regarding the importance of ligament replacement in existing osteoarthritis three topics are highlighted: the development of osteoarthritis after ACL-tear or -replacement, ACL-replacement in existing osteoarthritis and ACL-replacement together with medial unicompartmental knee replacement. Concomitant lesions at the meniscus and cartilage, especially the patella-femoral cartilage are risk factors for the development and progression of osteoarthritis in ACL insufficiency. The treatment of a symptomatic ACL-insufficiency in existing osteoarthritis in the elderly patient is directly dependent on pre-existing degenerative changes. Medial unicompartmental knee replacement and ACL-replacement can, however, be well combined and lead to very good long-term results even in the young patient.

[Diagnostic value of a 3D-SPACE-sequence with compressed sensing technology for the knee joint]. / Diagnostische Wertigkeit der 3­D-SPACE-Sequenz mit Compressed-sensing-Technologie am Kniegelenk.

BACKROUND: SPACE (3D fast spin echo acquisition) sequences require long scan times for three-dimensional assessment of acute injury of the knee joint and are flawed due to geometric blurring. Their implementation into routine diagnostic imaging was not feasible until recently. OBJECTIVES: By comparing conventional MRI (magnetic resonance imaging) sequences to 3D (three-dimensional) sequences, it was investigated whether the compressed sensing (CS) technique is inferior to the established 2D sequences with shorter examination times. MATERIALS AND METHODS: A total of 109 patients (age range 18-50 years) with knee injury were examined by MRI between April 2017 and May 2018. The inter- and intraobserver concordance of two blinded readers were assessed. Consensus was achieved in case of discrepancies. Descriptive analyses of absolute and relative frequency and distribution were tested by Fisher's exact test concerning differences between CS-SPACE and standard proton density fat suppressed imaging. RESULTS: Interoberserver concordance (IC) of conventional sequences before/after consensus amounted to 58.8/68.1% (medial meniscus, MM), 68.8/88.7% (lateral meniscus, LM) 88.9/97.2% (anterior cruciate ligament, ACL), 99/100% (posterior cruciate ligament, PCL), 88.9/97.2% (collateral ligament, CL) and chondral injury (CI) 1-2: 64.2%, CI-3: 77% and CI-4: 76%. The IC of CS-SPACE amounted before/after consensus of MM to 50.4/77%, LM 68.8/88%, ACL 89.9/94.5%, PCL 97.2/99.0%, CL 92.6/96.3%. IC of CI was evaluated without consensus and amounted to 65.1% (CI 1-2), 66% (CI 3) and 81.6% (CI 4). CONCLUSIONS: Injuries of ACL, PCL and CL have excellent IC between 3D and 2D sequences. Excellent IC could be found in CI grade 3 and 4 when using 2D sequences and CI grade 4 utilizing CS-SPACE. Our results indicate that CS-SPACE is useful in diagnosing acute knee injuries.

Patients' expectations of osteotomies around the knee are high regarding activities of daily living.

PURPOSE: This study was conducted to investigate patients' expectations on high tibial osteotomies, distal femur osteotomies, and double-level osteotomies in different health-related domains. It was hypothesized that expectations are high in terms of capacity to work, pain relief, and restoring knee function. METHODS: A total of 264 patients (age 47 years ± 11 years) were enrolled in this study from March 2015 until May 2016 in seven specialized orthopaedic surgery departments. Data were collected via the Knee injury and Osteoarthritis Outcome Score, the Hospital for Special Surgery-Knee Surgery Expectations Survey, and a ten-item (non-validated) questionnaire to specifically ask about expectations of osteotomies around the knee 24-48 h prior to surgery. In addition, self-efficacy was assessed. Parametric tests were used to test the hypothesis. RESULTS: Knee injury and Osteoarthritis Outcome Score test results showed that all patients suffered because of their knee impairments prior to surgery. All participants had high expectations in all aspects regarding the surgical outcome: on a four-point Likert scale ranging from 1 (very important) to 4 (not important), all mean values were between 1.2 and 1.7. For patients who had a demanding physical work, the ability to keep a stressful working posture was more important than for other patients (i.e. to kneel, to squat). Furthermore, preoperative lower quality of life was associated with higher expectations concerning improving the ability to walk, to achieve improvements in activities of daily living and social well-being. CONCLUSIONS: Patients' expectations of osteotomies around the knee are high in terms of capacity to work, pain relief, and restoring functions. The natural course of osteoarthritis and the potential need for conversion to TKA were underestimated by a substantial proportion of the study population. However, the expectation regarding survival rate is in line with the reported literature. The results of this study should assist surgeons in discussing realistic expectations when considering and counselling patients regarding osteotomies around the knee. This may help to clarify realistic expectations preoperatively and ultimately improve patients' satisfaction. LEVEL OF EVIDENCE: Therapeutic study, Level II.

Long-Term Radiographic Adaptations to Stress of High-Level and Recreational Rock Climbing in Former Adolescent Athletes: An 11-Year Prospective Longitudinal Study.

BACKGROUND: In the past few years, competition climbing has grown in popularity, and younger people are being drawn to the sport. PURPOSE: While radiographic changes in long-term climbers are known, there are little data available on adolescent climbers. The question arises as to whether climbing at high levels at a young age leads to radiographic changes and possibly an early onset of osteoarthritis of the finger joints. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 19 members of the German Junior National Team (GJNT group) and 18 recreational climbers (RC group) were examined clinically and radiographically in 1999. In 2011, these climbers were re-examined (mean follow-up, 11.3 ± 1.2 years). Radiographs were evaluated using a standard protocol, searching for physiological adaptations such as cortical thickness of the middle phalanx and an increased adopted Barnett-Nordin index, as well as for early-onset osteoarthritic changes of the hand. In contrast to the Kellgren-Lawrence scale, subchondral sclerosis was added to the group of physiological, adaptive stress reactions and was not defined as osteoarthritis. Osteoarthritis was defined by a Kellgren-Lawrence grade ≥2. RESULTS: Overall, 15 of 19 (follow-up rate, 78.9%) climbers in the GJNT group and 13 of 18 in the RC group (follow-up rate, 72.2%), with a mean age of 26.8 years, were examined at the 11-year follow-up. Five climbers (33%) in the GJNT group presented with a decreased range of motion for the finger joints, in contrast to only 1 climber (8%) in the RC group. Radiographic stress reactions of the hand were found in 80% of the GJNT group and 46% of the RC group, including cortical hypertrophy (GJNT: 73%; RC: 23%), subchondral sclerosis (GJNT: 80%; RC: 31%), a broadened proximal interphalangeal joint base (GJNT: 67%; RC: 38%), and a broadened distal interphalangeal joint base (GJNT: 53%; RC: 31%). Training intensity in 1999 and body weight in 1999 were significant for the development of radiographic stress reactions in 2011 (P < .05 for both). Signs of early-stage osteoarthritis were seen in 6 climbers: 4 (27%) in the GJNT group and 2 (15%) in the RC group. Significant statistical influences for the development of early-onset osteoarthritis were found for overall total training years (P = .024), use of campus board training in 1999 (P = .033), and climbing level (P = .030). CONCLUSION: One-quarter of climbers who performed at a high level in their youth showed a "mild" form of osteoarthritis (Kellgren-Lawrence grade 2). In analyzing the training regimens of our climbers for longer than 10 years, we conclude that intensive finger training (eg, campus board training) can lead to early-onset osteoarthritis of the hand. We also demonstrate that a high Union Internationale des Associations d'Alpinisme (UIAA) climbing level correlates with the risk for early-onset osteoarthritis of the hand and therefore must be seen as a risk factor for developing early-onset osteoarthritis of the finger joints.

Patient satisfaction with health is substantially improved following ACL reconstruction.

PURPOSE: To prospectively monitor health-related quality of life and return to work after arthroscopic anterior cruciate ligament (ACL) reconstruction in patients with isolated ACL tears. METHODS: Sixty consecutive patients with isolated ACL tears who underwent arthroscopic ACL reconstruction were prospectively monitored using the "Questions on Life Satisfaction Modules" (FLZM) and "Short-Form 12 (SF-12)" quality-of-life outcome measures. The Lysholm score and Tegner activity index were used as functional outcome measures. Additionally, return to work (months) together with level of physical workload was analysed. Outcome measures were assessed the day before surgery and at 6, 12 weeks and 6, 12, and 24 months post-operatively. Quality-of-life outcomes were correlated with functional outcome scores. RESULTS: Satisfaction with health (FLZM) significantly improved within the first 2 years (p < 0.05), and the physical component scale (SF12) showed a significantly higher score after 3, 6, 12 and 24 months as compared with preoperative values (p < 0.05). "General life satisfaction (FLZM)" was initially decreased at 6 weeks (p < 0.05) but increased during the further follow-up period, reaching a score not significantly different from preoperative values. Mean Lysholm score improved from 66 preoperatively to 89 post-operatively (p < 0.05) and the median Tegner activity index improved from four to six points (p < 0.05) at final follow-up. Mean time to return to work was 7 weeks (range 1-34 weeks), and it strongly depended on physical workload. A positive correlation between quality of life and functional outcome (Lysholm score) was observed. CONCLUSION: General life satisfaction is impaired during the early post-operative course, but returns to preoperative values after 2 years. Satisfaction with health reaches higher values after 6, 12 and 24 months post-operatively, and the SF-12 physical component scale was seen to improve during the follow-up period. Improved functional outcomes were observed to correlate with quality-of-life measurements. Thus, patients can preoperatively be informed that they will benefit from ACL reconstruction in terms of an improved knee function and satisfaction with health. Heavy physical workload must be considered as a risk factor for prolonged time lost to return to work. These patients have to be identified and informed about realistic expectations. LEVEL OF EVIDENCE: II.

The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence.

BACKGROUND: Failure rates of knee ligament surgery may be high, and the impact of osseous alignment on surgical outcome remains controversial. Basic science studies have demonstrated that osseous malalignment can negatively affect ligament strain and that realignment procedures may improve knee joint stability. HYPOTHESIS/PURPOSE: The purpose of this review was to summarize the clinical evidence concerning the impact of osseous malalignment and realignment procedures in knee ligament surgery. The hypotheses were that lower extremity malalignment would be an important contributor to knee ligament surgery failure and that realignment surgery would contribute to increased knee stability and improved outcome in select cases. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: According to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic electronic search of the PubMed database was performed in November 2015 to identify clinical studies investigating (A) the influence of osseous alignment on postoperative stability and/or failure rates after knee ligament surgery and (B) the impact of osseous realignment procedures in unstable knees with or without additional knee ligament surgery on postoperative knee function and stability. Methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and the Coleman Methodological Score (CMS). RESULTS: Of the 1466 potentially relevant articles, 28 studies fulfilled the inclusion and exclusion criteria. Average study quality was poor (CMS, 40). For part A, studies showed increased rerupture rate after anterior cruciate ligament (ACL) replacement in patients with increased tibial slope. Concerning the posterior cruciate ligament (PCL)/posterolateral corner (PLC)/lateral collateral ligament (LCL), varus malalignment was considered a significant risk factor for failure. For part B, studies showed decreased anterior tibial translation after slope-decreasing high tibial osteotomy in ACL-deficient knees. Correcting varus malalignment in PCL/PLC/LCL instability also showed increased stability and better outcomes. CONCLUSION: In cases of complex knee instability, the 3-dimensional osseous alignment of the knee should be considered (eg, mechanical weightbearing line and tibial slope). In cases of failed ACL reconstruction, the tibial slope should be considered, and slope-reducing osteotomies are often helpful in the patient revised multiple times. In cases of chronic PCL and/or PLC instability, osseous correction of the varus alignment may reduce the failure rate and is often the first step in treatment. Changes in the mechanical axis should be considered in all cases of instability accompanied by early unicompartmental osteoarthritis.

Health-related quality of life after open-wedge high tibial osteotomy.

PURPOSE: (1) To monitor longitudinal changes in health-related quality of life (HRQOL), pain, knee function, and return to work (RtW) following high tibial osteotomy (HTO) for medial compartment osteoarthritis (OA), and (2) to investigate the influences of psychopathological comorbidities on preoperative impairment and post-operative course. METHODS: Sixty-four patients were prospectively followed for 24 months after HTO to determine HRQOL, pain, functional outcome, and RtW. Psychopathological comorbidities (e.g. depression) were determined preoperatively. Patients with no psychological distress (ND) were compared to patients with psychological distress (PD) in order to investigate the influence of psychopathological comorbidities on outcome. RESULTS: There was a significant increase in HRQOL and decrease in pain from 6 month follow-up on. Functional outcomes increased significantly from 12 month follow-up on. In general, there was a steady state of outcomes from 6- to 12-month follow-up on. At final follow-up, 90 % returned to their previous occupation without limitations. Mental component summary (MCS) and functional outcome showed a positive correlation with RtW, while depression had a negative one. A significantly inferior outcome of group PD versus ND was observed at baseline and early follow-up. RtW was significantly prolonged in group PD (8.9 ± 7.6 vs. 3.9 ± 3 months; p < 0.001). At final follow-up, both groups presented with comparable outcomes. CONCLUSION: HTO for medial compartment OA significantly improves HRQOL, pain, and knee function. Time to RtW is high and critically depends on PD. Further, extend of preoperative impairments, an initially inferior course, and inferior MCS outcome was influenced by PD. However, otherwise no significant differences were observed between groups PD and ND at final follow-up. LEVEL OF EVIDENCE: Prospective case series, II.

ACL deficiency and varus osteoarthritis: high tibial osteotomy alone or combined with ACL reconstruction?

INTRODUCTION: This study investigates the mid- to long-term clinical and radiological outcome in patients with symptomatic varus osteoarthritis (OA) and deficiency of the anterior cruciate ligament (ACL) and analyzes whether there are differences between isolated high tibial osteotomy (HTO) or combined single-stage HTO and ACL reconstruction (ACLR). METHODS: 26 patients who underwent HTO alone (group 1) and 26 patients who underwent single-stage HTO and ACLR (group 2) because of varus OA and ACL deficiency were examined at a mean of 5.8 years (SD 3.6 years) post-operatively. Assessment at follow-up (FU) was performed using a questionnaire including clinical scores (Lysholm, IKDC) and the KT-2000 arthrometer to examine anterior knee stability. Radiographic knee alignment and signs of OA according to the classification of Kellgren and Lawrence (KL) were assessed pre-operatively and at FU. RESULTS: Eighty-one percent of all patients reported an improvement of pain and 79% an improvement of instability without significant group difference. Significant worse results were observed in group 1 for the Lysholm score (group 1: 69.4, SD 15.7; group 2: 78.3, SD 16.4; p = 0.020) and the IKDC score (group 1: 64.8, SD 13.0; group 2: 74.0, SD 15.6; p = 0.006). No group difference was found for the KT-2000 examination. A significant post-operative increase of radiographic OA could be seen in both groups without significant group difference (KL pre-operative: 2.3, SD 0.63; KL FU: 2.8, SD 0.74; p < 0.001). The radiographic leg alignment at FU showed a significant lower valgus alignment in group 1 (group 1: 0.4 degree, SD 3.3 degree; group 2: 2.1 degree, SD 2.1 degree; p = 0.039). The rate of post-operative complications was low with 4%, and no significant group differences were found. CONCLUSIONS: This study shows that HTO alone can improve pain and even subjective knee stability. Additional ACLR was in the mid term not associated with a higher increase of OA or a higher rate of post-operative complications in our study collective.

The role of bone void fillers in medial opening wedge high tibial osteotomy: a systematic review.

PURPOSE: A variety of bone void filling materials and methods are available in opening medial wedge HTO (OWHTO). The pertinent question revolves around if and when bone void fillers are needed. The primary purpose of this study was to systematically review outcomes and complications after OWHTO with and without the use of bone void fillers. METHODS: The EMBASE, PubMed\MEDLINE, Cochrane Library and Google Scholar databases were searched to identify articles that reported OWHTO results using different bone void fillers until March 2016. Only articles reporting the exact bone void filler type, the opening gap size and the fixation method were included. The extracted data included the study design, demographic data, the radiological and clinical results and complication rates. Outcomes were analysed with regard to bone void filler type, and comparison was made between the groups (allograft, autograft, synthetic bone void filler and OWHTO without bone void filling). RESULTS: Twenty-two articles reporting the results of 1421 OWHTO met the inclusion criteria. In total, 647 osteotomies were completed with allogeneic graft as bone void filler, 367 with synthetic materials, 199 with autograft and 208 without any bone void filling material. The maximum opening gap size was similar in all groups with mean of 9.8 mm (range 4-17.5 mm). Locking plate fixation was used in 90 % of the osteotomies that were completed without bone void filler, while all allograft cases and more then 90 % of the autograft cases were done with non-locking systems. The highest rates of non-union (1.1 %) were seen in the synthetic group, compared to 0.5 % in the all the other groups. CONCLUSIONS: This systematic review showed no definitive advantages for OWHTO with any bone void filler in terms of union rates and loss of correction. Moreover, the use of autografts or allografts showed more favourable outcomes than synthetic bone substitutes. OWHTO with gaps smaller then 10 mm and rigid fixation might be successfully managed without bone grafting. However, when bone grafting is needed, autograft bone provides higher rates of clinical and radiographic union. The use of synthetic bone substitutes in OWHTO cannot be recommended. LEVEL OF EVIDENCE: III.

Analysis of the effects of high tibial osteotomy on tibial rotation.

PURPOSE: Limited literature reports on internal and external rotation of the distal fragment in the context of valgus open wedge (OW) high tibial osteotomy (HTO). In the authors clinical observation, the distal fragment was always rotated internally in relation to the proximal fragment by the end of the surgical procedure. The purpose was to evaluate the influence of valgus OW-HTO on post-operative tibial torsion. STUDY DESIGN: Prospective case series. METHODS: Fifty patients (10 female, 40 male; mean age 42.1 ± 9.4 years) underwent valgus OW- HTO. The osteotomy was spread and fixed with a locking plate at the posteromedial aspect of the proximal tibia. The osteotomy of the tibial tuberosity was performed either proximally or distally dependent on the patello-femoral findings. Two independent observers measured axial tibial rotation using K-wires placed into the anterior margin of the tibia proximal and distal to the osteotomy. RESULTS: An overall mean of 4.4 ± 2.8° internal rotation of the distal tibia has been shown. In four patients with additional single step double bundle ACL-replacement after harvesting ipsilateral autologous hamstring grafts, the distal tibia rotated internally by 0.1 ± 0.3°, accordingly in the other 46 patients by 4.8 ± 2.6°. CONCLUSIONS: Valgus OW-HTO produces significant internal axial rotation of the distal tibia. This might be caused by soft tissue tension of the medial hamstrings/soft tissue structures and the location of the lateral tibial hinge. CLINICAL RELEVANCE: Surgeons have to take into consideration that valgus OW HTO might result in significant 3D changes of the tibia. Higher degrees of internal torsion of the tibia might influence overall gait mechanics and specifically alternate patellofemoral kinematics.

Can young and active patients participate in sports after osteochondral autologous transfer combined with valgus high tibial osteotomy?

PURPOSE: To evaluate sporting activity following osteochondral autologous transfer (OAT) combined with valgus high tibial osteotomy (HTO) in young and active patients with focal osteochondral defects of the medial femoral condyle and concomitant varus malalignment. METHODS: Thirty patients with focal osteochondral defects of the medial femoral condyle and varus malalignment >2° were enrolled. All patients were active in sports on a regular base prior to surgery (lifetime), but were unable to perform sports at the time of surgery. Sporting activity 1 year preoperatively and at final follow-up was compared using a previously published sports questionnaire, which assesses sports level, number of sports disciplines, sports frequency, sports duration and the participation in 32 common sports disciplines. Additionally, the Tegner activity scale and the Activity Rating Scale were used. RESULTS: After a mean follow-up of 6.9 years (2.5-9.8; SD 2.4), 76.7 % of patients were participating in sports on a regular basis (Fig. 2). Compared to 1 year preoperatively, there was no difference (n.s.) with regard to sports, the number of sports disciplines, sports frequency and sports duration (Fig. 4). The median Tegner activity scale measured preoperatively 5.0 (2.0-7.0) and post-operatively 5.0 (4.0-7.0) points (Fig. 3), and the ARS changed from 5.7 to 5.3 points (n.s.). The different types of sports disciplines were comparable between 1 year preoperatively and at follow-up. CONCLUSION: A high return to sports rate and an activity level comparable to the state at 1 year preoperatively can be expected in young and active patients after combined OAT and valgus HTO. This seems to be relevant in clinical practice when planning, indicating and performing these complex procedures. LEVEL OF EVIDENCE: IV.

Patient expectations of primary and revision anterior cruciate ligament reconstruction.

PURPOSE: Unrealistic patient expectations have been shown to negatively influence patient-reported outcomes in orthopaedic surgery. Knowledge about patient expectations is important to associate preoperative expectations with the reasonable outcome of a specific procedure. The purpose of this study was to prospectively analyse and to compare patient expectations of primary and revision anterior cruciate ligament reconstruction (ACLR) and to assess the factors associated with patient expectations. METHODS: Preoperative expectations of 181 consecutive patients undergoing ACLR were assessed prospectively using a 5-item questionnaire. Primary ACLR (P-ACLR) was performed in 133 patients (73%), whereas 48 patients (27%) underwent revision ACLR (R-ACLR). The questionnaire assessed the expectation of the overall condition of the knee joint, return to sports, instability, pain, and risk of osteoarthritis. RESULTS: All patients expected a normal (38%) or nearly normal (62%) condition of the knee joint. Return to sports at the same level was expected by 91%. With regard to instability (pain), no instability (pain) independent of the activity level was expected by 77% (58%). No or only a slightly increased risk of the development of osteoarthritis was expected by 98%. The R-ACLR group showed a significantly lower expectation of the overall condition (p = 0.001), return to sports (p < 0.001), and pain (p = 0.002). No statistically significant difference was found between female and male patients (n.s.). In the P-ACLR group, patients with a history of previous knee surgery showed inferior expectations of return to sports (p = 0.015) and risk of osteoarthritis (p = 0.011). Age, number of previous knee surgeries, and pre-injury sports level significantly influenced patient expectations. CONCLUSIONS: Overall, patient expectations of ACL reconstruction are high. Patients undergoing revision ACL reconstruction have lower but still demanding expectations. Younger patients, patients without a history of knee surgery, and highly active patients have higher expectations. Explicit patient information about realistic goals of ACL reconstruction seems to be necessary in order to prevent postoperative dissatisfaction despite a successful operation in the surgeons' point of view. LEVEL OF EVIDENCE: Prospective case series, Level IV.