Meniscal Repair Outcome in 3829 Patients With a Minimum Follow-up From 2 Years Up to 5 Years: A Meta-analysis on the Overall Failure Rate and Factors Influencing Failure.

BACKGROUND: The importance of meniscal repair is widely accepted because of the association of loss of meniscal tissue with the development of early-onset knee arthritis. Many factors influencing the results of meniscal repair have been reported, but results remain controversial. PURPOSE: This meta-analysis determines the pooled meniscal repair failure rate of studies with a minimum follow-up of 2 years up to 5 years, with a mean follow-up of 43 months. Moreover, selected failure-influencing factors are analyzed. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed and Scopus were searched for studies published between January 2000 and November 2021 reporting on meniscal repair outcome with a minimum follow-up of 24 months. The overall pooled failure rate and pooled failure rates for possible predictors were calculated. Random-effect models were used to pool failure rates, and effect estimates in the form of odds ratios with 95% CIs were established. RESULTS: The initial literature search identified 6519 studies. A total of 51 studies met the inclusion criteria. In total, 3931 menisci were included with an overall failure rate of 14.8%. Subgroup analysis revealed a significantly lower failure rate for meniscal repair with concomitant anterior cruciate ligament (ACL) reconstruction compared with knees without any reported injury to the ACL (8.5% vs 14%; P = .043). The pooled failure rate for lateral meniscal repair was significantly lower than that for medial meniscal repair (6.1% vs 10.8%; P = .031). Pooled failure rates of all-inside and inside-out repair were not significantly different (11.9% vs 10.6%; P > .05). CONCLUSION: This meta-analysis on close to 4000 patients demonstrates an overall meniscal repair failure rate of 14.8% at a minimum follow-up from 2 years up to 5 years. Meniscal repair remains a procedure with a high failure rate, especially within the first 2 postoperative years. This review and meta-analysis also identified clinically relevant factors associated with favorable outcomes such as concomitant ACL reconstruction or repair of the lateral meniscus. All-inside meniscal repair with the latest-generation devices yields failure rates of <10%. The failure mechanism and the time of failure is poorly documented; further studies are needed for a better understanding of the retear mechanism.

Surgical treatment of chronic proximal patellar tendon tears grades 3 and 4 using augmentation with quadriceps tendon-bone graft.

BACKGROUND: Chronic proximal patellar tendinosis with partial tendon tears represents a multifactorial overuse injury. Several surgical techniques have been described with various outcomes and the return to sports may fail. HYPOTHESIS: Reconstruction of the proximal patellar tendon with augmentation using a quadriceps tendon-bone (QTB) graft improves knee function in patients presenting with proximal patellar tendinosis and partial tendon tears. METHODS: Forty-seven patients (32 males, 15 females) with chronic proximal patellar tendinosis and tendon tears grade 3 and 4 were treated between 1992 and 2018. Patients were evaluated retrospectively using the Popkin-Golman (PG) MRI grading system and the removed tendon parts. The Tegner Activity Scale (TAS) and the Numerical Rating Scale (NRS) for pain were used as outcome measures before surgery and at follow up. Complete data were available in 100% of cases at 6 months follow up, and fifteen of them at later follow up. RESULTS: The average follow up was 1.5 years (range, 0.5-16). The TAS improved from a mean preoperative score of 3.7 to a mean postoperative score of 9.1. The median NRS status decreased from an average of 6.4 to 1.1. Two patients needed additional arthroscopic scar tissue removal. CONCLUSION: Reconstruction of proximal patellar tendon tears grades 3 and 4 with augmentation using a QTB graft is a valuable surgical salvage procedure in chronic cases. It improves knee function and yields good to excellent results in most cases including high level athletes. The use of MRI with the PG classification of tendon tears is highly recommended. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

[Qatar 2022 : challenges and implications related to the medical follow-up of a national football team]. / Qatar 2022 : enjeux et implications liées au suivi médical d'une équipe nationale de football.

The preparation and medical follow-up of a national team during a major tournament, in particular climatic conditions and at an unusual date posed several problems, acclimatization, recovery in connection with a busy championship game, seasonal risk of infection, which had to be resolved. Close collaboration between the various people involved, team manager, coaches, physiologist, fitness coach and doctors is essential in order to prepare to face the challenges to be met to accompany an ambitious team.

La préparation et le suivi médical d'une équipe nationale lors d'un tournoi majeur dans des conditions climatiques et à une date inhabituelle a posé un certain nombre de problèmes : acclimatation, récupération en lien avec une partie de championnat chargée, risque saisonnier infectieux, qu'il a fallu résoudre. Une collaboration étroite entre les différentes personnes concernées, team manager, entraîneurs, médecin-physiologiste, entraîneur de condition physique et médecins, est indispensable afin de se préparer à faire face aux défis à relever pour accompagner une équipe ambitieuse.

Impact of COVID-19 Vaccination on Short-Term Perceived Change in Physical Performance among Elite Athletes: An International Survey.

COVID-19 vaccination raised concerns about its potential effects on physical performance. To assess the impact of COVID-19 vaccination on the perceived change in physical performance, we conducted an online survey among elite athletes from Belgium, Canada, France and Luxembourg, with questions about socio-demographics, COVID-19 vaccination, perceived impact on physical performance and perceived pressure to get vaccinated. Full vaccination was defined as two doses of mRNA or vector vaccine or a heterologous vaccine scheme. Among 1106 eligible athletes contacted, 306 athletes answered the survey and were included in this study. Of these, 72% perceived no change in their physical performance, 4% an improvement and 24% a negative impact following full COVID-19 vaccination. For 82% of the included athletes, the duration of the negative vaccine reactions was ≤3 days. After adjustment for potential confounding variables, practicing an individual sport, a duration of vaccine reactions longer than 3 days, a high level of vaccine reaction and the perceived pressure to get vaccinated were independently associated with a perceived negative impact on physical performance of more than 3 days after the vaccination. The perceived pressure to get vaccinated appears to be a parameter associated with the negative perceived change in the physical performance and deserves further consideration.

Subjective knee apprehension is not associated to physical parameters 6-12 months after anterior cruciate ligament reconstruction.

PURPOSE: Anterior cruciate ligament (ACL) rupture is a common injury and psychological parameters measured at 6-8 months are said to be almost more predictive for return to sport (RTS) than physiological. Purpose was 1) to evaluate the correlation between knee apprehension using ACL-RSI and physical factors after ACL reconstruction (ACLR), 2) to assess the correlation between ACL-RSI and patient parameters (age, pivot-sport, BMI), and 3) to evaluate ACL-RSI over time. METHODS: Patients with ACLR with or without meniscal repair between 2013 and 2020 were retrospectively analyzed. Including criteria were RTS testing battery, assessed at least 6 months after surgery, including physical parameters (strength, triple hop test, side hop test, and bilateral knee stability) and psychological parameters (ACL-RSI). 5 subgroups were analyzed to assessed factors such as age, BMI, pivot sport, time interval between two RTS testing battery. RESULTS: Three hundred three patients (212 male, 91 female) presenting ACLR were included. Mean age at surgery was 27 (± 8) years. 258 patients practiced pivot-sport activity and 45 non-pivot-sport activity. The mean interval between ACL rupture and surgery was 6.5 (± 4.5) months. RTS testing battery were performed at 8 (± 7) months after ACLR. Mean ACL-RSI was 58 (± 28). 1) ACL-RSI was not influenced by muscle strength, coordination and stability of the knee. 2) ACL-RSI was significantly better in lower BMI and non-pivot-sport activities. No correlation was found between graft type, age, sex, and ACL-RSI assessment. 3) For patients who performed two RTS testing battery at 8 and 12 months, ACL-RSI did not significantly increase over time (56 to 64 points, p = 0.22) in spite of significant increased quadriceps (127 to 151 Nm/kg, p = 0.005) and hamstring (93 to 105 Nm/kg, p = 0.05) strength. CONCLUSIONS: Psychological readiness before RTS, measured upon ACL-RSI does not correlate with any physical parameter at 8-12 months postoperatively. Although quadriceps and hamstring strength increased significantly over time, ACL-RSI does not and must therefore be routinely assessed.

[How and why to monitor apprehension after anterior cruciate ligament surgery]. / Évaluation de l'appréhension avant la reprise de sport suite à la chirurgie du ligament croisé antérieur - Comment la monitorer et pourquoi ?

Numerous studies highlight the psychological aspect being the most frequent factors limiting the resumption of sport, following an anterior cruciate ligament reconstruction surgery, even before strength, the capacity of performing high impact pivoting movements, endurance, or joint stability. Scores that quantify apprehension, have been developed as clinical tool to monitor psychological readiness and in some cases to delay the moment for return to sport. Unfortunately, there are no established cut-off values for these scores to predict when and if return to sport at the same level as pre-traumatically can be resumed. The psychological aspect of return to sport remains individual, and influenced by age, type, and level of physical activity.

De nombreuses études mettent en avant l'aspect psychologique comme étant l'un des principaux facteurs limitant la reprise de sport après reconstruction du ligament croisé antérieur, même avant le manque de force, les sauts et mouvements en pivot à haute intensité, l'endurance ou la stabilité mécanique du genou. Des scores, permettant de quantifier le degré d'appréhension, ont été élaborés afin de suivre la confiance ressentie du patient lors de mouvements liés au sport et de retarder la reprise sportive si nécessaire. Malheureusement, pour l'instant, aucun consensus n'est établi dans la littérature autour d'une valeur seuil de ces différents scores pour la reprise de sport. L'interprétation de ces scores reste pour l'instant une évaluation individualisée, influencée par l'âge, le type et le niveau du sport pratiqué par le patient.

[Approach to the athlete with low back pain]. / Prise en charge de la lombalgie chez l'athlète.

Low back pain is a common symptom in athletes, hindering their activity. The etiology is tightly linked to the type of sport, often a consequence of repetitive movements, high pressures and strain being applied to the spine and adjacent muscular and ligamentous structures and a high degree of activity. The diagnosis is the key and causes are usually not severe. However, some red flags may indicate a more serious origin. Treatment is mostly conservative and based on functional therapies with the goal of a rapid and secure return to sports. As such, sedentary lifestyle should be avoided.

La lombalgie est un symptôme courant chez les athlètes pouvant entraver leur pratique sportive. L'étiologie est intimement liée au type d'activité pratiquée, souvent secondaire aux mouvements répétitifs, aux forces appliquées sur les structures musculosquelettiques et au degré d'activité. Le diagnostic clinique reste essentiel pour la prise en charge et les causes sont le plus souvent peu sévères. Des drapeaux rouges peuvent néanmoins alerter la présence d'une atteinte grave nécessitant une prise en charge urgente. L'imagerie immédiate étant indiquée uniquement en leur présence. Le traitement est dans la majeure partie des cas conservateur et basé sur les thérapies fonctionnelles dans l'objectif d'un retour sécuritaire au sport de prédilection dès que possible. La sédentarité, quant à elle, est à proscrire.

Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: a systematic review and meta-analysis with a minimum follow-up of 5 years.

PURPOSE: Meniscus repair has gained increasing interest over the last two decades as loss of meniscus tissue predisposes to early onset knee arthritis. Although there are many reports of meniscus repair outcome in short-term studies, data on the long-term outcome of meniscus repair are still scarce. The purpose of this meta-analysis was to evaluate the overall failure rate of meniscus repair with a minimum follow-up of 5 years. Additionally, possible factors influencing meniscus repair outcome were assessed. METHODS: PubMed and Scopus were searched for studies of the last 20 years reporting on meniscus repair outcome with a minimum follow-up of 5 years. The study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search terms used for this study were ([meniscus OR meniscal] AND repair). Titles and abstracts were evaluated by two authors independently. Using meta package of R (version 3.6.2), random-effect models were performed to pool failure rates. Subgroup analyses were performed and effect estimates in form of an odds ratio with 95% CIs were established. RESULTS: In total, 12 studies with 864 patients were included. Degenerative tears were excluded in two studies and one study only included traumatic meniscus tears. Other studies did not state whether the cause of meniscus tear was degenerative or traumatic. Studies reporting meniscus repair outcome on root repairs, revision anterior cruciate ligament reconstruction, discoid menisci or ramp lesions were excluded. Revision surgery was used as failure definition in all included studies. The overall failure rate of meniscal repair at a mean follow-up of 86 months was 19.1%. There was no significant difference in meniscus repair outcome when performed in combination with anterior cruciate ligament reconstruction compared to isolated meniscus repair (18.7% vs. 28%; n.s.) or when performed on the lateral meniscus compared to the medial meniscus (19.5% vs. 24.4%; n.s.). There was no significant difference of meniscus repair outcome between vertical/longitudinal tears and bucket-handle tears (n.s.). Thirty-six percent of meniscus repair failures occur after the second postoperative year. The only significant finding was that inside-out repair results in a lower failure rate compared to all-inside repair (5.6% vs. 22.3%; p = 0.009) at 5 years. CONCLUSION: The overall meniscus repair failure rate remains nineteen percent in long-term studies. The cause of failure is poorly documented, and it remains unclear whether failure of the meniscus repair itself or additional adjacent tears lead to revision surgery. Despite the given technical advantages of all-inside repair devices, this meta-analysis cannot demonstrate superior outcomes compared to inside-out or outside-in repair at 5 years. LEVEL OF EVIDENCE: IV.

[Classification and treatment of modern traumatic meniscal tears]. / Classification et traitement modernes des déchirures méniscales traumatiques.

The menisci have several important biomechanical functions. Traumatic meniscal injuries present a wide spectrum of presentation and several types of lesions. They can concern the body of the meniscus and its fixation. An easy and clear classification of traumatic meniscus tears is essential for helping the physicians to achieve the correct surgical indication and the accurate postoperative rehabilitation protocol. The aim of this current concept review is to clearly describe some classical as well new type of meniscal and menisco-synovial lesions such as ramp lesions, root tears and instability of the lateral meniscus associated to rotational laxity. The goal is to focus on the definition, diagnosis, classification, giving some guidelines and discussing the different rehabilitation protocols.

Les ménisques sont essentiels au fonctionnement biomécanique du genou. Les lésions méniscales traumatiques peuvent se manifester par des tableaux cliniques très variés et concerner le corps du ménisque, ses attaches à l'os ou à la capsule articulaire. Une classification simple et claire des déchirures méniscales traumatiques est indispensable. Cette revue de la littérature contemporaine fait un tableau précis des lésions méniscales traumatiques classiques et « nouvelles ¼ telles que celles de la rampe, les avulsions de la racine méniscale et l'instabilité du ménisque externe associée à une laxité rotatoire du genou, en se focalisant sur la définition de chacune de ces déchirures, leur diagnostic, leur classification, afin de proposer des directives de traitement et de rééducation.

[Should allografts become gold-standard in ligamentous knee surgery ?] / Qu'en est-il des allogreffes pour la chirurgie ligamentaire du genou ?

Allografts in reconstructive knee surgery are an interesting option, due to the absence of donor site morbidity, its rather easy intraoperative handling, the different sizes, shorter surgical time, and therefore less peroperative risks. The risk of infection is very low. Their results are similar when non-irradiated and non-sterilized allografts are used in terms of postoperative strength, return to sport, and comparable stability testing. Nevertheless, allografts have not yet become current practice, due to the costs, the availability, its structural integration and ligamentisation process that might be prolonged and its increased re-rupture rate in the young and active population. Its undeniable value for multiligamentous or complexe knee reconstruction is however undeniable, which should however be reserved for specialized centers.

L'allogreffe dans la chirurgie ligamentaire du genou semble être une option intéressante au vu de l'absence de site de prélèvement, d'une facilité d'utilisation, d'un choix des propriétés, d'une durée chirurgicale raccourcie et donc de risques peropératoires diminués. Le risque de transmission infectieuse est très faible. Ses résultats sont comparables à la chirurgie par autogreffe uniquement si non irradiée et non stérilisée en termes de force, retour au sport, et comparables ou légèrement inférieurs en termes de stabilité. Les allogreffes ne sont pas devenues pratiques courantes, en raison des coûts, de la disponibilité, d'une intégration, d'une transformation biologique prolongée et du taux de reruptures plus élevé chez les jeunes patients actifs. Les allogreffes sont par contre indispensables pour les reconstructions multiligamentaires et des révisions complexes.

Exercise-Based Injury Prevention in High-Level and Professional Athletes: Narrative Review and Proposed Standard Operating Procedure for Future Lockdown-Like Contexts After COVID-19.

In regular times, implementing exercise-based injury prevention programs into the training routine of high-level and professional athletes represents a key and challenging aspect to decrease injury risk. Barriers to implementing such prevention programs have previously been identified such as lack of resources, logistic issues or motivation. The COVID-19 pandemic associated with restrictions on daily life dramatically impacted sports participation from training to competition. It is therefore reasonable to assume that such lockdown-like context has exacerbated the challenge to implement exercise-based injury prevention programs, potentially leading to a greater musculoskeletal injury risk. In this narrative review, recommendations are proposed for building an expertise- and evidence-based Standard Operating Procedure for injury prevention in lockdown-like contexts for high-level and professional athletes. The following recommendations can be provided: (1) assess the global and sport-specific risks in the light of the ongoing cause of isolation; (2) adapt remote training materials and programs; (3) ensure regular quality communication within the staff, between athletes and the staff as well as between athletes; (4) follow the athlete's mental well-being; and (5) plan for a safe return-to-sports as well as for an ongoing monitoring of the load-recovery balance. These key domains should further be addressed to comply with local policies, which are subject to change over time in each individual country. The use of these recommendations may improve the readiness of athletes, coaches, physicians and all sports stakeholders for future lockdown-like contexts.

[Evolution of thromboprophylaxis after hip and knee arthroplasties]. / Évolution de la thromboprophylaxie après prothèses de hanche et de genou.

Venous thrombotic events frequently complicate major elective arthroplasties such as hip and knee replacements. The risk of proximal deep vein thrombosis and pulmonary embolism is estimated at 5 %. For decades, the use of low-dose heparins for up to 5 weeks post-surgery has helped to reduce the risk of thrombotic complications. In this narrative review, we describe the evidence supporting the use of direct oral anticoagulants (in Switzerland - rivaroxaban and apixaban), whose risk-benefit ratios appears superior to that of heparins, at a lower cost. Hybrid strategies combining a short-term anticoagulant followed by low-dose aspirin are also recommended for patients deemed at low thrombotic risk.

Les thromboses veineuses profondes proximales et les embolies pulmonaires sont des complications redoutées après des interventions électives majeures en chirurgie orthopédique (prothèses totales de la hanche et du genou), avec une incidence cumulée estimée à 5 %. Depuis des décennies, ce risque est réduit par l'utilisation d'héparine à dose préventive jusqu'à 5 semaines postopératoires. Dans cette revue narrative, nous décrivons les évidences motivant l'utilisation des anticoagulants oraux directs (rivaroxaban et apixaban en Suisse) qui semblent présenter un rapport bénéfice-risque supérieur aux héparines, à un coût moindre. Des stratégies hybrides comprenant un anticoagulant puis l'aspirine sont désormais également recommandées chez des patients considérés à bas risque thrombotique.

The influence of a meniscal bucket handle tear on the Posterior Cruciate Ligament Angle in Anterior Cruciate Ligament Rupture - A case report.

INTRODUCTION: Chronic anterior cruciate ligament (ACL) tear might be difficult to diagnose on MRI. Indirect signs might be a typical meniscal or cartilage lesion, or a spontaneous anterior drawer visualized by a decreased angle of the posterior cruciate ligament (PCL). PRESENTATION OF CASE: A 27-year-old former ballet dancer was admitted to the emergency department for a locked left knee, without never having experienced previous symptoms of giving way or locking. The MRI performed revealed a medial meniscus bucket handle tear, without traumatic bone marrow oedema or ligament injury. The PCL angle was 130°. A former MRI of her left knee performed 1 year previously to investigate on the recurrent catching of her left knee showed a grade III medial meniscal tear of the posterior horn, and buckling of the PCL angle of 100°, as a sign of chronic ACL rupture. During arthroscopy and medial meniscal repair, the ACL showed complete loss of tension, and was therefore reconstructed simultaneously to enable proper meniscal healing. DISCUSSION AND CONCLUSION: Chronic ACL insuffiency is a major risk factor for subsequent medial meniscus tear, especially bucket handle tear. The locked knee might unable proper pre-operative clinical examination. The preoperative MRI therefore being the only possibility to diagnose concomitant ligamentous injury. This is the first case reported in literature showing, that a positive PCL angle sign might be falsely negative due to a locked medial meniscus bucket handle tear.

3D-printed anatomic models of the knee for evaluation of patellofemoral dysplasia in comparison to standard radiographs and computed tomography.

PURPOSE: To evaluate 3D-printed anatomic models of the distal femur and patella for diagnosis and classification of patellofemoral dysplasia in comparison to conventional radiographs (CR) and CT. METHOD: Following local ethics committee approval, CT-datasets of 50 patients were segmented and 3D-anatomic models of the distal femur and patella were printed. An expert panel reviewed CR, CT, 3D-models and patient history and classified the femoral trochleas into normal or Dejour type A-D and the patellas into Wiberg type A-C, which served as the standard of reference. The same classifications were performed by two readers independently, first based on 3D-models and after 3 weeks based on CR and CT. Descriptive statistics, ROC-analysis and inter-reader reliability were performed. RESULTS: Trochlear dysplasia was present in 28/50 patients. Evaluations of 3D-models vs. CR/CT for trochlear dysplasia showed a sensitivity/specificity of 89.3 %/100 % vs. 96.4 %/68.2 % for reader 1 and 96.4 %/100 % vs. 96.4 %/90.9 % for reader 2, and an area under the curve of 0.946 vs. 0.823 for reader 1 (p = 0.029) and 0.982 vs. 0.937 for reader 2 (p = 0.147). Evaluations of 3D-models vs. CR/CT for the Dejour classification showed a sensitivity/specificity of 32.1 %/100 % vs. 57.1 %/68.2 % for reader 1 and 46.4 %/100 % vs. 50 %/90.9 % for reader 2 without significant differences. No significant differences existed for Wiberg-classification (50-66 % exact matches) or inter-reader reliabilities between 3D-models and CR/CT for all assessments (Kappa 0.428-0.92). CONCLUSION: In comparison to radiographs and CT, 3D-models achieve similar diagnostic accuracy for detection of patellofemoral dysplasia and have the potential to improve diagnosis for less experienced physicians.

Every second retired elite female football player has MRI evidence of knee osteoarthritis before age 50 years: a cross-sectional study of clinical and MRI outcomes.

PURPOSE: To assess knee health in retired female football players, using magnetic resonance imaging (MRI) and self-report. The focus of analysis were degenerative changes of the tibiofemoral joint, and their relationship to osteoarthritis symptoms and previous knee injury. METHODS: Forty-nine retired elite, female football players (98 knees) aged 37 years on average participated. Tibiofemoral cartilage and meniscus status of both knees were evaluated using MRI and graded according to modified Outerbridge and Stoller classifications, respectively. Symptoms were assessed through a standardised questionnaire (Knee Osteoarthritis Outcome Score: KOOS). Knee injury history was recorded via a semi-structured interview. To investigate how injury variables relate to outcomes, binary logistic regression models were used and reported with odds ratios (OR). RESULTS: Fifty-one per cent of players (n = 25) fulfilled the MRI criterion for knee osteoarthritis, 69.4% (n = 34) had substantial meniscal loss and 59.6% (n = 28) reported substantial clinical symptoms. Chondral- and meniscal loss were associated with significantly lower scores on three of five KOOS subscales (p < .05). Both chondral and meniscal loss were significantly predicted by previous traumatic knee injury (OR = 4.6, OR = 2.6), the injury affecting the non-striking leg (OR = 8.6, OR = 10.6) and type of injury; participants with combined ACL/meniscus injuries had the highest risk for substantial chondral and meniscal loss (OR = 14.8, OR = 9.5). Chondral loss was significantly predicted by isolated meniscus injury treated with partial meniscectomy (OR = 5.4), but not by isolated reconstructed ACL injury. Clinical symptoms were only significantly predicted by previous traumatic knee injury (OR = 5.1). CONCLUSIONS: Serious degenerative changes were found in a high number of retired female football players' knees 10 years after their career. Meniscal integrity is key for knee osteoarthritis outcomes in young adults, and thus, its preservation should be a priority.

Neither lateral patellar facet nor patellar size are altered in patellofemoral unstable patients: a comparative magnetic resonance imaging analysis.

PURPOSE: It remains unclear if morphologic patterns of the patella itself predispose to patellar instability. This study examined established patellar landmarks in relation to the femoral condyle width to clarify differences of patellar morphologies in patellofemoral stable and unstable patients. METHODS: Magnetic Resonance Imaging of 50 subjects (20.7 ± 4.4 years; 17 males, 33 females) with patellofemoral instability (study group, SG) and 50 subjects (25.3 ± 5.8 years; 31 males, 19 females) with anterior cruciate ligament rupture (control group, CG) were analyzed. Corresponding patellar value indices (PW-I; LPF-I 1; LPF-I 2) in relation to the femoral condyle width (FCW) were evaluated after the measurement of absolute patellar dimension [patellar width (PW); direct length of the lateral patellar facet (LPF-1); projected length of the lateral patellar facet (LPF-2)]. The patellar shape according to Wiberg, trochlear dysplasia, patellar height, and tibial tubercle-trochlear groove (TT-TG) distance were determined. RESULTS: The SG showed a significantly longer absolute (LPF 2) (P = 0.041) and relative (LPF-I 1, LPF-I 2) (P < 0.001) lateral facet of the patella. No significant differences were evaluable for the relative patellar width (PW-I) (ns). A patellar shape type 3 (P = 0.001) as well as a higher position of the patella and TT-TG-distance (P < 0.001) were significantly more often present in the SG. CONCLUSION: There are several bony alterations associated with patellofemoral instability, but our data did not show a significantly smaller lateral patellar facet or relative patellar width that could facilitate a patellar dislocation. This helps surgeons, that are considering to surgically address the patella in cases of patellofemoral instability, to better understand its morphologic pattern. LEVEL OF EVIDENCE: III.

Bone autografting in medial open wedge high tibial osteotomy results in improved osseous gap healing on computed tomography, but no functional advantage: a prospective, randomised, controlled trial.

PURPOSE: Medial open wedge high tibial osteotomy (owHTO) is a valuable surgical technique used to manage medial degeneration in varus knees. Iliac crest autograft is considered the gold standard gap-filler. It was hypothesised that iliac crest autograft promotes gap healing and improves functional outcome in owHTO. METHODS: Between 2005 and 2009, patients scheduled to undergo owHTO stabilised by a medial locking compression plate were randomised to undergo owHTO either with iliac crest autograft (group A) or without bone void filler (group B). Pre- and postoperative leg axes were recorded. At 3 and 12 months postoperatively, the healing of the osteotomy gap was measured as a percentage on CT images, and functional scores were recorded. RESULTS: There were 15 patients in group A, and 25 in group B. The groups were similar in age, sex ratio, knee varus deformity, body mass index, and smoking status. Group A and B had similar preoperative varus (6.9° vs. 7.6°) and postoperative valgus (2.2° vs. 3.0°). Compared with the control group, group A had a significantly greater degree of osseous gap healing after 3 months (40.1% vs. 10.8%, p = 0.045) and 12 months (91.5% vs. 59.1%, p ≤ 0.001). Multiple linear regression analysis found that bone grafting was an independent promoting factor for gap healing, while increased preoperative varus was an independent retardant factor at 3 months (p = 0.004 and p = 0.002, respectively) and 12 months (p ≤ 0.001 and p = 0.003, respectively). Younger age was a promoting factor for gap healing on CT at 3 months (p ≤ 0.001), but not at 12 months. No correlations were found between bone healing and functional outcome, body mass index, or smoking status. CONCLUSIONS: Iliac crest autograft significantly increases healing of the osteotomy gap after owHTO. Increased preoperative varus and older patient age are independent factors that delay early healing of the osteotomy. However, no functional advantage was found at 3 or 12 months postoperatively. Therefore, routine use of iliac crest autograft cannot be recommended. LEVEL OF EVIDENCE: II.

[Return to sport and to competition after anterior crusiate ligament reconstruction.] / Retour au sport et à la compétition après reconstruction du ligament croisé antérieur.

The return to sport (RTS) and return to competition (RTC) after anterior cruciate ligament reconstruction (ACLR) in the recreational and professionnel sports population remains a challenge. Previous level of activity, associated injuries, the type of reconstruction, and rehabilitation associated factors such as strength, neuromuscular control, and mobility all influence the RTS and RTC. Psychologic aspects, overall fitness, and patient's expectations equally play an important role. ACLR rehabilitation needs ideally a multi-disciplinary setting and follows functional steps rather than chronological time-lines, with passing criteria until RTS and RTC. Standardized and sport-specific tests are mandatory to evaluated optimal readiness for RTS and RTC.

Le retour au sport (RTS) et à la compétition (RTC) du patient sportif amateur ou d'élite après une reconstruction du ligament croisé antérieur (RLCA) est une décision importante qui nécessite un avis éclairé et partagé entre les différents intervenants dans le traitement. Le niveau et le type d'activité prélésionel, les facteurs liés à la blessure comme les lésions associées, le type de réparation, et ceux liés à la rééducation comme la force, les compétences neuromusculaires et la mobilité influencent tous le RTS et le RTC, sans compter les aspects psychologiques, le niveau de fitness, les attentes et la situation personnelle du patient. La rééducation se fait par étapes fonctionnelles avec des critères de passage jusqu'au RTS et RTC, en collaboration multidisciplinaire. Des tests standardisés et spécifiques au sport pratiqué sont finalement nécessaires pour valider l'aptitude au retour au sport et à la compétition.

The Relationship of Femoral Tunnel Positioning in Medial Patellofemoral Ligament Reconstruction on Clinical Outcome and Postoperative Complications.

PURPOSE: To analyze the relation of the femoral tunnel (FT) positioning on clinical outcome. METHODS: Patients with recurrent patellar dislocation who underwent medial patellofemoral ligament (MPFL) reconstruction with or without tibial tubercle osteotomy between 1998 and 2012 were included in this retrospective study. Strict postoperative lateral radiographs were mandatory. Knees with previous osseous stabilization surgery, fixed lateral patellar dislocation, valgus knee (>5°), or open growth plates were excluded. The distance between the FT and the validated radiographic landmark (the "Schoettle point") was measured. An FT with a distance greater than 10 mm was considered as malpositioned. The distance was correlated to subjective outcome measurements (patient satisfaction and Kujala score) and postoperative complications (a loss of range of motion and revision surgery). RESULTS: Sixty-three knees in 60 patients (aged 23.7 ± 7.5 years at the time of surgery, 79.4% female) were included with a mean follow-up of 5.7 ± 3.3 years. The FT showed an average distance of 13.3 mm (±6.0 mm; 95% confidence interval [CI]: 11.7-14.8) to the Schoettle point, and 45 of 63 knees (71.4%) were deemed malpositioned. The postoperative Kujala score of malpositioned FT (75.9 points; 95% CI: 71.2-80.7) was not significantly inferior to knees with an FT within 10 mm (80.5; 95% CI: 73.7-87.3, P = .315). However, all 5 knees that underwent revision surgery showed an FT outside the 10-mm area. CONCLUSIONS: Malpositioning of the FT in MPFL reconstruction is associated with postoperative complications. However, a malpositioned FT in MPFL reconstruction will not necessarily lead to an unsatisfactory subjective or objective clinical outcome. Other factors, such as surgical indication or graft tensioning, might also significantly influence postoperative outcome. LEVEL OF EVIDENCE: Level IV, case-control study.