Acromioclavicular joint separation treated with clavicular hook plate: a study of radiological and functional outcomes.

INTRODUCTION: ACJ separation is a common shoulder injury. A variety of surgical techniques for high-grade ACJ separations have been described. A commonly used technique represents open reduction and fixation by a hook plate. Goal of the present study was to evaluate radiographic and functional outcome in patients with high-grade ACJ separations following surgical treatment with a hook plate before and after surgery as well as after hook plate removal. MATERIALS AND METHODS: Patients undergoing surgery with a hook plate due to traumatic ACJ separation between 2012 and 2014 were included and examined during a follow-up control. Demographic and clinical data as well as radiographs pre- and postoperatively were evaluated. Additionally, range of motion, DASH Score and Constant-Murley Score (CMS) were analysed in a follow-up examination. Wilcoxon signed-rank test and Spearman's rank correlation were used for statistical analysis. RESULTS: 99 patients (88 m/11 w, 44 y) were included in the present study. 69 (64 m/5 w, 49 y) could be examined during long-term follow-up (38 month). After hook plate removal, the CCD increased significantly (13.7 ± 0.9 mm) compared to the hook plate in situ (9.9 ± 0.8 mm, p = 0.000001). 68% of all patients achieved a full range of motion post-operatively. Main limitations of range of motion affected external rotation as well as ante-/retroversion. Mean DASH Score was 5.6 ± 1 points and CMS 90.0 ± 1.4 points. CONCLUSION: In contrast to a significant higher CCD after hook plate removal, nearly all patients achieved good to excellent functional results for DASH and CMS. This indicates that loss of reduction does not necessarily lead to poor functional outcome after ACJ separation surgery.

Complications after surgical management of proximal humeral fractures: a systematic review of event terms and definitions.

BACKGROUND: The most frequently used surgical procedures for treating a proximal humeral fracture (PHF) are plate osteosynthesis, nail osteosynthesis and arthroplasty. Evidence-based recommendations for an appropriate surgical procedure after PHF requires transparent and valid safety data. We performed a systematic review to examine reported terms and definitions of complications after surgically-treated PHFs. METHODS: A literature search was conducted on PubMed, Cochrane Library, EMBASE, Scopus and WorldCat to identify clinical articles and book chapters on complications of PHF published from 2010 to 2017. Complication terms and definitions were extracted from each selected article independently by two reviewers and grouped according to a predefined scheme. RESULTS: From 1376 initial references, we selected 470 articles, of which 103 were reviewed in reverse chronological order until no further information was gained. Twelve book chapters were reviewed. We found 667 local event terms associated with complications after surgical treatment of PHFs. The most frequently used event terms were infection (52 references), nonunion (n = 42), malunion (n = 35), avascular necrosis (n = 27) and pain (n = 25). Overall, 345, 177, 257 and 102 local event terms were related to plating, nailing, arthroplasty and other surgical techniques, respectively. Radiological assessment was the basis for the majority of event terms and complication definitions. Thirty-six event definitions were extracted, mostly defining the terms "secondary fracture displacement", "screw perforation/cutout", "malunion", "delayed healing" and "notching". CONCLUSION: Scientific literature on surgically-managed PHF uses different terms to describe complications and without approved definitions, which highlights a lack of agreement on adverse event terminology for PHFs. Defined event terms are mostly based on radiological observations. Consensus among shoulder surgeons on a core event set is indispensable to support the standardization of safety reporting for surgically-treated PHFs.

Trends in fracture development of the upper extremity in Germany-a population-based description of the past 15 years.

BACKGROUND: Recent studies investigating fracture development in Germany are not available especially with regard to demographic change. The primary aim of this study was to report trends in fracture development of the upper extremity in Germany between 2002 and 2017 and to evaluate changes over time. METHODS: Evaluating inpatient data from the German National Hospital Discharge Registry (International Classification of Diseases, ICD-10) between 2002 and 2017. Total count, incidences and percentage changes of the following fracture localizations were analysed: proximal humerus, distal humerus, proximal ulna, proximal radius, ulna diaphysis (including Monteggia lesion) and distal radius. Ten age groups for men and women were formed: 35-44, 45-54, 55-64, 65-74; 75-84; 85-90, and > 90 (years). RESULTS: The total count of proximal humeral fractures increased from 40,839 (2002, men/women 9967/30,872) to 59,545 (2017, men/women 14,484/45,061). Distal humeral fractures increased from 5912 (2002, men/women 1559/4353) to 6493 (2017, men/women1840/4653). The total count of forearm fractures increased from 68,636 (2002, men/women 17,186/51,450) to 89,040 (2017, men/women 20,185/68,855). Women were affected in 70-75% of all cases with rising incidences among nearly every age group in female patients. CONCLUSION: Total count of nearly every evaluated fracture increased. Also, incidences increased especially in the older female age groups. Fracture development already seems to reflect demographic changes in Germany.

[Trochanteric and subtrochanteric fractures]. / Per- und subtrochantäre Femurfrakturen.

Proximal femoral fractures are one of the most common fractures, particularly in older people. The most common cause is a falling event due to dizziness and gait insecurity. In most cases prompt surgical treatment is necessary to achieve early mobilization and to reduce the risk of mortality. The aim is a stable osteosynthesis and patient-centered care. A great variety of implants are available for this purpose. Furthermore, perioperative management is important to prevent further problematic events, such as delirium, reoccurrence of falling events and to diagnose and adequately treat a pre-existing osteoporosis.

[Malnutrition in Elderly Trauma Patients - Comparison of Two Assessment Tools]. / Die Erfassung des Ernährungsstatus alterstraumatologischer Patienten ­ ein Vergleich zweier etablierter Screeningmethoden.

Background: The prevalence of malnutrition in hospitalised patients is reported to be between 16 and 55 % across disciplines. Within hospital care, screening for malnutrition is required. However, in orthopaedics and trauma surgery, there is still no generally accepted recommendation for the methods for such a data survey. In the present study, the following aspects are to be investigated with the help of two established scores: (1) the prevalence of malnutrition in the patient population of geriatric trauma care, and (2) the correlation between methods of data survey. Material and Methods: Between June 2014 and June 2015, a consecutive series of hospitalised trauma patients were studied prospectively with two validated screening instruments to record nutritional status. The study was carried out at a municipal trauma surgery hospital, which is a first level interregional trauma centre as well as a university hospital. The Nutritional Risk Screening (NRS) and the Mini Nutritional Assessment (MNA Short and Long Form) were used. All patients were divided into three age groups: < 65 years, 65-80 years, and > 80 years. The prevalence of malnutrition in geriatric trauma patients and the correlation between the screening instruments were determined. For a better comparison, prescreening and main assessment were applied to all patients. For statistical evaluation, both quantitative and semi-quantitative parameters were used. Furthermore, the Kolmogorov-Smirnov test, Spearman's correlation analysis and the chi-square test were applied. These tests were two-sided and had a level of significance of 5 %. The present study was partially funded by the Oskar-Helene-Heim Foundation. Results: 521 patients (43.8 % women, 56.2 % men), with a mean age of 53.96 ± 18.13 years, were statistically evaluated within the present study. Depending on the method of the data survey, malnutrition (NRS≥3) in geriatric trauma patients varied from 31.3 % (65-80 years) to 60 % (> 80 years). With MNA, 28.8 and 54.3 % of patients were at risk of malnutrition (MNA 17-23.5), while the fractions of patients already suffering from malnutrition (MNA < 17) were 5.4 and 8.6 %, respectively. The correlation between the NRS and MNA total scores increases with the age of the patients. The correlation coefficient for patients under 65 years is r = - 0.380, while among patients aged between 65 and 80, it is r = - 0.481, and for patients over 80 years, there is a medium to strong correlation of r = - 0.638 (each with a Spearman correlation of p < 0.001). For the total population as well as the different age groups, statistically significant correlations were recorded between the categorised scores (chi-square test for linear trend, p < 0.001). Summary: The present study demonstrates high prevalence of malnutrition among the geriatric trauma patients. Because of its easy and rapid application, the NRS has an advantage in clinical use. It was shown that the two methods of data survey were highly correlated.

[Retrospective Analysis of Diabetics with Regard to Treatment Duration and Costs]. / Retrospektive Analyse von Diabetikern im Hinblick auf Behandlungsdauer und Behandlungskosten in einem überregionalen Traumazentrum.

Background: The increasing incidence of diabetes mellitus is also reflected in the patient population of a trauma and orthopaedic centre. Diabetics also exhibit more comorbidities than non-diabetics. In addition to surgical problems in these patients, hospitalisation is often accompanied by complications, which can prolong treatment and increase costs. The aim of this retrospective study is to analyse hospitalisation of diabetics compared to non-diabetics, as well as differences in treatment costs, depending on associated age and comorbidities. Patients/Material and Methods: 17,185 patients were treated at a transregional trauma and orthopaedic centre and were included in this retrospective analysis between 2012 and 2015. Comorbidities and hospitalisation of diabetics and non-diabetics were recorded. All costs charged by DRG were evaluated to calculate the cost per day and per patient, on the basis of the specific case rate. In this calculation, patient-related case rates were divided by the average residence time and the means of the calculated daily rates were calculated. Inclusion criteria were treatment within the various departments and a minimum hospitalisation of one day. Statistical analysis was performed with the SPSS program (version 22.0, SPSS Inc., Chicago, USA). Results: In comparison to non-diabetics (ND), diabetics (D) exhibited significantly more comorbidities, including: obesity, arterial hypertension, coronary heart disease, myocardial infarction (in the history), peripheral arterial disease, chronic kidney disease and hyperlipidaemia. Pneumonia in hospital was considerably commoner in diabetics (2.45 % [D] vs. 1.02 % [ND], p < 0.001). Time in hospital was significantly longer in diabetics (endoprosthetics 13.52 days [D] vs. 12.54 days [ND], p < 0.001; septic surgery 18.62 days [D] vs. 16.31 days [ND], p = 0.007; traumatology 9.82 days [D] vs. 7.07 days [ND], p < 0.001). For patients aged under 60 years, time in hospital was significantly longer for diabetics than for non-diabetics (9.98 days [D] vs. 6.43 days [ND] p < 0.001). Because of the longer time in hospital, treatment costs were higher by € 1,932,929.42 during the investigated time period. Conclusion: Because of their comorbidities, diabetics need to be categorised at an early stage as high-risk patients in traumatological and orthopaedic departments. Hospitalisation and the associated increased treatment costs, as well as postoperative complications, could be minimised in patients with diabetes by implementing an interdisciplinary treatment concept.

[Is it Possible to Arouse Interest in a Career in Traumatology with a Curricular Course in Medical School?] / Kann mit praxisorientierter curricularer Lehre das Interesse am Fach Orthopädie und Unfallchirurgie geweckt werden?

Background: There is a serious lack of young doctors in trauma surgery, which has intensified in recent years. The reasons are complex. Studies have shown that the interest in starting a career in surgery significantly decreases during medical school. To counteract the lack of young talent in the clinic, interest in the subject should be aroused in medical school. The aim of the present study was to evaluate current teaching at our university, where trauma surgery is a curricular subject with mandatory attendance for all medical students. Material and Methods: The current curriculum is intended for medicine students in their fifth year. The curriculum comprises lectures, practical courses and observation modules held in small groups. Students are provided with an experienced surgeon as teacher and mentor for the whole week. A teaching and training centre is available for the practical courses. In an anonymised questionnaire, students were asked about their overall assessment and the training success of practical and theory-oriented modules, as well as their specific interest in traumatology. Results: The evaluated curriculum gave very good results, with an overall rating of 1.53 (average) on a 6-point Likert scale in the overall assessment. It could be shown that students previously not interested in starting a career in trauma surgery showed significantly more interest in the subject after the curriculum. The practical parts scored best in the individual assessment. Conclusion: We showed that intensive teaching can arouse interest in traumatology in students who had been indifferent to orthopaedics and traumatology.

[Treatment of proximal humeral fractures in Germany: Influence of the level of hospital care and the frequency of treatment]. / Behandlung proximaler Humerusfrakturen in Deutschland: Einfluss von Krankenhausversorgungsstufe und Behandlungsfrequenz.

BACKGROUND: Various treatment options exist for displaced proximal humeral fractures. The impact of the level of hospital care and frequency of treatment on current treatment regimens in Germany was analyzed. MATERIAL AND METHODS: A total of 576 hospitals were included. The survey covered questions on frequency, diagnostics, classification, therapy, complications, and clinical scenarios. RESULTS: In all, 48% of the hospitals returned the questionnaire: 73% treat more than 60% of the fractures surgically, mainly with angle-stable implants. The angle-stable plate is the treatment of choice for young patients, but older patients are treated using other treatment options. Problems and complications included malreduction, secondary displacement, screw perforation, avascular necrosis, and impingement. According to treatment indication, implant choice, and common complications, no significant differences between the level of hospital care and frequency of treatment were observed. CONCLUSION: Independent of the level of hospital care and frequency of treatment, there is a trend for head-preserving angular-stable surgery with a homogenous level of treatment in Germany.

[Evaluation of a strategy for the management of accompanying osteoporosis after inpatient treatment of fragility fractures]. / Analyse einer poststationären Behandlungsstrategie nach osteoporose-assoziierter Fraktur.

AIM: The aim of the present study was to evaluate a strategy for the management of accompanying osteoporosis after inpatient treatment of fragility fractures. METHOD: A prospective group of patients that was treated for acute fragility fractures between 9/05 and 2/06 was informed about a concomitant osteoporosis according to the national guidelines. Standardised letters with instructions for diagnostics and therapy for osteoporosis were given to patients, members of the family and outpatient care, rehab-clinic and GPs. Between 9/04 and 2/05 a retrospective review of a control group of patients with acute fragility fractures was conducted. This group was not informed about a concomitant osteoporosis. A telephone survey of all patients for analysis of the management of osteoporosis was conducted one year after clinical treatment. RESULTS: Both groups were comparable according to numbers of patients, age, distribution between the sexes and fracture localisation. The prospective group consisted of 144 patients. 29.9 % of these patients had already sustained a fragility fracture before treatment of the current fracture. In 45.8 % (32.6 % DEXA scans, 11.8 % Q CT, 1.4 % ultrasound) of the patients diagnostics were performed. A diagnosis of osteoporosis was documented in 42.4 % of the patients, and 57.1 % of the patients received specific treatments according to the guidelines. In the control group, 28.9 % of the patients had already sustained a fragility fracture before treatment of the current fracture. In 91.1 % of the patients no diagnostics for concomitant osteoporosis after clinical treatment for the acute fracture were performed within one year after fracture treatment. CONCLUSIONS: By use of a multifaceted osteoporosis intervention, more patients received diagnostics and therapy according to the guidelines of osteoporosis after fragility fractures. Without appropriate information, more than 60 % of the high-risk-patients did not receive adequate osteoporosis management. Future research should address barriers to appropriate osteoporosis management. Because of the chronic character of the disease and the necessity of a long-term therapy, continuous medical care and information of patients with osteoporosis is necessary to prevent subsequent fractures.

[Bilateral hip dislocation in cerebral palsy children: conservative therapy of the less affected hip and adductor tenotomy of the opposite hip]. / Beidseitige Hüftgelenksluxation bei infantiler Zerebralparese: konservative Therapie der weniger betroffenen Seite bei gegenseitiger Adduktorentenotomie.

AIM: In cerebral palsy children with bilateral hip dislocation, a new therapeutic concept was established that treated the less affected hip conservatively and the more affected hip simultaneously with an adductor tenotomy. The current study assessed whether the clinical and radiological outcome was equal to that of established bilateral surgical treatments. We also examined whether this approach leads to an adequate motor function improvement of the affected children. METHOD: In 41 children with cerebral palsy and bilateral hip dislocation, a prospective study assessed the hip abduction, migration percentage (MP) and the motor function (Rancho los Amigos scale). Depending on the pretherapeutic status, all patients were grouped into 3 abduction and 3 MP groups. The less affected hip was treated with a hip abduction splint whereas the more affected hip of the same child was simultaneously treated with a subcutaneous adductor tenotomy. All patients were assessed annually for 4 years. RESULTS: The hip abduction of the conservatively treated hips was pretherapeutically 41.8 +/- 2.6 degrees and improved significantly after 1 year. Patients with a pretherapeutic hip abduction < or = 20 degrees showed the most improvement. After 4 years, a significant deterioration of abduction was avoided in 49%. The pretherapeutic MP of the conservatively treated hips was 31.6 +/- 3.4% and was significantly but only slightly improved. The 4 year MP was significantly improved and the largest improvement was observed when the pretherapeutic MP was larger than 50%. A significant MP improvement after 4 years was achieved in 54%. After 4 years, 34% had undergone a motor function improvement. In 7% a motor function deterioration was observed. Posttherapeutically, the conservatively treated hips showed abduction and MP values that were comparable to those of surgically treated hip joints. CONCLUSION: In cerebral palsy children with bilateral hip dislocation, the conservative treatment of the less affected hip is suitable to achieve clinical and radiological results that are equal to the surgical treatment of the more affected hip. The concept of a combined conservative and surgical treatment of bilateral hip dislocation leads to an adequate motor function improvement that is comparable to established bilateral treatments.

[Prophylaxis and therapy for hip dislocations in patients with infantile cerebral palsy (ICP): motor functional, radiological and clinical results after subcutaneous adductor tenotomy]. / Prophylaxe und Therapie der Hüftgelenksluxation bei infantiler Zerebralparese (ICP): statomotorische, radiologische und klinische Ergebnisse nach subkutaner Adduktorentenotomie.

AIM: The current study assessed the clinical and radiological outcome and motor function improvement after subcutaneous adductor tenotomy in children with cerebral palsy (ICP). It was also analysed if groups with different preoperative hip functions and radiological hip migrations differed in their final clinical, radiological and motor function outcome. METHOD: A prospective study of 91 children with infantile cerebral palsy (ICP, mean age 4.9 years, range: 1.1 - 15.8) with 141 hip dislocations or subluxations analysed preoperatively the hip abduction and radiologically the migration percentage (MP). Depending on the preoperative status, all patients were grouped into 3 abduction and 3 MP groups. Additionally, the motor function was classified according to the Rancho los Amigos scale. A subcutaneous adductor tenotomy was performed mono- or bilaterally and all patients were treated for 4 - 6 weeks with a hip abduction splint. Patients were assessed annually for 4 years; clinical and radiological results and the motor function were analysed according to their preoperative status. RESULTS: The mean hip abduction was preoperatively 30.3 +/- 1.2 degrees and was significantly improved to 50.3 +/- 1.3 degrees 1 year and to 43.3 +/- 2.2 degrees 4 years post surgery. The preoperative mean MP was preoperatively 42.3 +/- 1.3 % and was significantly improved to 34.6 % 1 year and to 31.9 % 4 years post surgery. After 4 years, 41 % had undergone a motor function improvement and 52 % no change in motor function. After 4 years, patients with a hip abduction

3-Dimensional ultrasound imaging for meniscal lesions.

PURPOSE: The aim of this prospective study was to evaluate preoperative three-dimensional ultrasound scans for the detection of meniscal lesions with a special focus on interobserver reliability. METHODS: Forty one patients with clinical signs of meniscal lesions were preoperatively examined by ultrasound using the 3-D technique (11.7 MHz linear transducer). The 3-D dataset was stored and examined by a second orthopaedic surgeon. The second ultrasound examiner was blinded to the results of the first. Any meniscal pathology was confirmed arthroscopically and documented. RESULTS: At arthroscopy eight lateral meniscal lesions and 57 medial meniscal lesions were detected at different locations. The sensitivity and specificity of the original ultrasound examination was acceptable whereas the results of the second ultrasound session were not as sensitive. CONCLUSION: Three-D-ultrasound with a high resolution transducer, in the hands of an experienced operator, provides acceptable results in the detection of meniscal lesions, however, analysis of the volume dataset from the 3-D ultrasound investigation indicates that it does not offer sufficient accuracy for clinical use.

[T-plate osteosynthesis--an obsolete osteosynthesis procedure for proximal humeral fractures? Middle-term clinical and radiological results]. / Die T-Platten-Osteosynthese - ein überholtes Osteosyntheseverfahren für proximale Humerusfrakturen? Mittelfristige klinisch-radiologische Ergebnisse.

AIM: The present clinical trial was performed to assess the clinical and radiological outcome after operative treatment of proximal humeral fractures using the T-plate. METHODS: All patients who were treated with the T-plate were included into the study. Patient satisfaction,complications and radiological findings were assessed. The clinical results were evaluated using the Constant-Murley score, the UCLA score, and the DASH score. Between December 1996 and October 2003, 74 patients (with 76 fractures)were treated with the T-plate. Surgically treated complications were 2 hematomas and 3 failures of the osteosynthesis under functional physiotherapy. In 19 patients the implants were removed because of persisting complaints. RESULTS: After an average follow-up period of 67 months 52 patients (54 fractures) were examined. According to the Neer classification there were 34 2-part, 15 3-part and 5 4-part fractures.80% of the patients were satisfied with the result. According to the evaluated scores, 74 to 89% of the patients had an excellent to satisfactory outcome. CONCLUSION: The T-plate enables the stable fixation of complex proximal humeral fractures and permits even in the elderly patient an early functional treatment. Anatomical reconstruction and stable fixation followed by early rehabilitation are most important to achieve a good functional outcome in the patient.

[Value of three-dimensional ultrasound and MRI in meniscal lesions]. / Wertigkeit von 3D-Sonographie und MRT des Meniskusschadens.

BACKGROUND: The aim of this prospective study was the evaluation of preoperative three-dimensional ultrasound in detecting meniscal lesions compared to preoperative MRI. METHODS: A total of 34 patients with clinical signs of meniscal lesions were examined preoperatively (11.7 MHz linear transducer) using the 3-D technique. Before ultrasound, MRI was performed, the results of which were unknown to the ultrasound examiner. The basis of the MRI result was the radiologist's written report. Arthroscopically the meniscal situation was noted and taken as reference. RESULTS: At arthroscopy there were 10 lateral meniscal lesions at different locations and 47 medial meniscal lesions at different locations. The sensitivity (0.5-0.78) and specificity (0.75-0.95) of both imaging methods were overall comparable. CONCLUSION: Ultrasound with the three-dimensional technique and high-resolution transducer in the hands of an experienced operator gives results comparable to the MRI interpretation by a general radiologist in detecting meniscal lesions.

[Marburg shoulder radiography splint (MSR splint) for standardized and high quality plain film radiography in fractures of the proximal humerus]. / Eine neue Lagerungsschiene zur Standardisierung und Qualitätsverbesserung der Röntgendiagnostik bei proximalen Humerusfrakturen.

To ensure safe, quick, pain-relieving, standardized, and reproducible high quality plain film radiography in fractures of the proximal humerus, the MSR splint was introduced into clinical practice. With the rectangular and completely radiolucent splint the shoulder radiographs are obtained in supine position by a sole radiographer. Two radiographs are taken in projection at 90 degrees to one another: the true anteroposterior and axillary views, the most important views for fracture visualization and assessment. The smooth flat bottom part of the splint glides easily across the X-ray table below the injured shoulder. The arm lying on the chest is carefully rotated externally up to the neutral position and placed in the splint, then fixed with Velcro fastening with the forearm supinated. The splint is adjusted to the patient for the anteroposterior view which is taken with the central ray directed at the coracoid process and perpendicularly on the film cassette. For the axillary view the MSR splint holding the upper extremity is carefully swiveled into a 80-90 degrees abduction position. Even in cases of comminuted fractures this maneuver is not painful for the patients. The X-ray tube is put into a horizontal position with the central ray pointing to the humeral head in an angle about 25 degrees to the long body axis. The cassette is placed upright in touch with the shoulder girdle. In our institution the MSR splint is not only routinely used for diagnosing fractures of the proximal humerus but also for radiological follow-up controls.

Metallic versus bioabsorbable interference screw for fixation of bone-patellar tendon-bone autograft in arthroscopic anterior cruciate ligament reconstruction. A preliminary report.

We retrospectively compared the clinical outcome and the radiographic incorporation of the bone blocks between two groups of patients undergoing anterior cruciate ligament reconstruction using either metallic or bioabsorbable interference screws for fixation of the bone-patellar tendon-bone autograft. Sixty-nine patients (44 male and 25 female) were available for follow-up. There were 31 patients with a mean age of 33 years (range 16-59 years) in group I (bioabsorbable interference screw fixation) and 38 patients with a mean age of 32 years (range 18-58) in group II (metallic screw fixation). The mean follow-up was 9.6 months after surgery in group I (range 6-17 months) and 20.5 months in group II (range 6-32 months). At follow-up, the IKDC scores were comparable between the two groups, and there was no statistically significant difference for the Lysholm (P = 0.925) and Tegner (P = 0.197) scores. The KT-2000 tests showed a statistically insignificant mean side-to-side difference of 2.0 mm (+2.2 mm SD) in group I and 2.2 mm (+2.4 mm SD) in group II (P = 0.741). At follow-up, all patients showed osseous incorporation of the bone block autografts within the femoral and tibial bone tunnels with no osteolytic changes.