Direct contact and very rapid valgus distortion characterise the injury mechanism of anterior cruciate ligament ruptures in judo.

PURPOSE: To analyse anterior cruciate ligament (ACL) rupture (ACLR) injury mechanisms in competitive judo using systematic video analysis, focusing on contact situations and biomechanics. METHODS: Seventeen videos of judo competitions wherein athletes developed ACLRs were included and retrospectively evaluated by five analysts. In all videos, the moment of initial contact and the index frame were defined. The judo techniques leading to the injury; the occurrence of direct contact, indirect contact or noncontact mechanisms; the time interval between the initial contact and index frame; the positions of the hip, knee and foot in relation to the initial contact and index frame; and the balance status during the initial contact and index frame were recorded. RESULTS: Eleven (65%) of ACLRs in judo involved direct contact. The mean time interval between initial contact and index frame was 15 ± 22 ms. Thirteen (77%) athletes were not balanced at initial contact. In the index frame, the hip was abducted in all cases and in combination with internal rotation in 12 (71%) cases. From initial contact to index frame, hip flexion increased in all cases; at index frame, the knee joint was internally rotated relative to the trunk in 12 (71%) cases, and the knee flexion angles increased from the initial contact. In the index frame, the foot was externally rotated relative to the knee in 12 (71%) cases, and severe valgus development of the knee with valgus collapse was observed in 14 (82%) cases. CONCLUSIONS: A direct attack on the knee was the most common injury mechanism observed. Valgus distortion appears to be the most important component of the mechanism of injury. With this knowledge, 'modified defence reactions' for specific judo techniques can be developed to reduce the injury risk. LEVEL OF EVIDENCE: Level IV.

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment.

PURPOSE: The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS: For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE: Level V.

Varus osteotomy as a salvage procedure for young patients with symptomatic patellofemoral arthritis and valgus malalignment at short- to mid-term follow-up: a case series.

PURPOSE: The purpose of the study was to report the clinical, functional and radiological outcome following varus osteotomy as a salvage procedure in young to middle-aged patients with patellofemoral arthritis (PFA) and associated valgus malalignment. It was hypothesized that a significant improvement in knee function and reduction in pain would be achieved. Moreover, no conversion to patellofemoral joint arthroplasty could be observed. MATERIAL AND METHODS: Patients (< 50 years of age) that underwent varus osteotomy between 08/2012 and 01/2020 for the treatment of symptomatic PFA and associated valgus malalignment were consecutively included (minimum follow-up: 24 months). Patient-reported outcome measures (PROM; International Knee Documentation Committee subjective knee form [IKDC]), Visual Analog Scale [VAS] for pain, Tegner Activity Scale [TAS], and satisfaction with the postoperative results (1-10-scale, 10 = highest satisfaction) and weight-bearing whole-leg anteroposterior radiographs were conducted pre- and postoperatively. The change in PROM and femorotibial angle (FTA) were tested for statistical significance. RESULTS: In total, 12 patients (14 knees) were included (66.7% female; mean age: 33.8 ± SD 6.6 years). In ten cases, lateral opening-wedge distal femoral osteotomies (DFO) were performed, of which three cases included a concomitant femoral derotation. Three medial closing-wedge DFO and one medial closing-wedge high tibial osteotomy were performed. At follow-up (55.3 ± 29.3 months), a significant improvement in knee function (IKDC: 56.4 ± 14.4 to 69.1 ± 11.2, p = 0.015) and reduction in pain (VAS for pain: 3.5 [interquartile range 2.3-5.8] to 0.5 [0-2.0], p = 0.018) were observed. Patients were able to reach their preoperative sporting activity level (TAS: 3.0 [3.0-4.0] to 3.5 [3.0-4.0], p = 0.854) and were highly satisfied with the postoperative result (9.0 [6.5-10]). Additionally, a significant correction of valgus malalignment was observed (5.0° ± 2.9° valgus to 0.7° ± 3.2° varus, p < 0.001). Regarding complications, two re-osteosyntheses were performed due to loss of correction and delayed union. No conversion to patellofemoral arthroplasty occurred. CONCLUSION: In patients with symptomatic PFA and associated valgus malalignment, varus osteotomy as a salvage procedure achieved a significant improvement in knee function and reduction in pain. No conversion to patellofemoral joint arthroplasty occurred at short- to mid-term follow-up. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Favorable rates of return to activity and work following lateral closing wedge distal femoral osteotomy for femoral-based symptomatic varus malalignment: an analysis at a mean 6-year follow-up.

PURPOSE: To evaluate return to sport (RTS), work (RTW) and clinical outcomes following lateral closing wedge distal femoral osteotomy (LCW-DFO) for symptomatic femoral varus malalignment. METHODS: Consecutive patients who underwent LCW-DFO for symptomatic varus malalignment between 12/2007 and 03/2018 were included. The International Knee Documentation Committee (IKDC) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, Tegner Activity Scale, and visual analogue scale (VAS) for pain were collected preoperatively and at a minimum of 24 months postoperatively. RTS and RTW were assessed by questionnaire. RESULTS: Thirty-two patients (mean age: 45.9 ± 12.3 years), who underwent LCW-DFO for femoral-based varus malalignment (6.4 ± 3.0°), were included at a mean follow-up of 72.7 ± 39.1 months. The patient collective significantly improved in IKDC (51.8 ± 12.3 to 61.8 ± 21.5, p = 0.010; 95% CI = 3-21), WOMAC (26.7 ± 17.6 to 12.5 ± 13.5; p < 0.001; 95% CI = 21-6) and Lysholm (46.5 ± 19.4 to 67.9 ± 22.8 points (p < 0.01; 95% CI = 9-31)) scores at final follow-up. The VAS for pain reduced significantly postoperatively (4.8 ± 2.3 points to 2.6 ± 2.3 points (p = 0.002; 95% CI = 0-3)). Following LCW-DFO, 96% of patients returned to sports at a mean of 5.3 ± 2.9 months. Yet, a shift to lower impact sports compared to one year preoperatively was observed, with patients participating in a significantly lower number of high-impact disciplines (p = 0.024) and fewer hours in high-impact sports (p = 0.034). Twenty-three out of 24 patients returned to work at a mean 11.4 ± 10.9 weeks, with 18 patients reporting a similar or superior working ability. CONCLUSION: Undergoing isolated LCW-DFO for symptomatic femoral-based varus malalignment enabled the vast majority of patients to RTS and RTW along with a significant functional improvement at mid-term follow-up. However, patients' expectations have to be adequately managed regarding a limited probability to return to high-impact sports and work after surgery. LEVEL OF EVIDENCE: Retrospective case series; Level IV.

Favorable long-term clinical and radiologic outcomes with high survivorship after autologous osteochondral transplantation of the talus.

PURPOSE: To evaluate long-term clinical and radiologic outcomes of patients undergoing autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and to perform a correlation analysis between clinical and radiologic outcomes. METHODS: Thirty-five patients with a mean age of 32.2 ± 8.9 years undergoing AOT for OLT between 1997 and 2003 were available for follow-up after an average of 19.1 ± 1.4 years. Demographic, surgical, and injury-related data were collected. After a minimum 18-year follow-up, patient-reported outcome scores (PROs) were collected, including the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Foot and Ankle Outcome Score (FAOS), Tegner Activity Scale, and Visual Analogue Scale (VAS) for pain of the ankle. The Lysholm Score and VAS for pain of the knee were collected to assess donor-site morbidity. Magnetic resonance imaging scans were obtained to conduct an assessment of the replaced cartilage using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 scoring system. Any revision surgery (except symptomatic hardware removal and arthroscopic debridement) was defined as clinical failure. RESULTS: Favorable clinical and radiologic (MOCART score, 73.7 ± 16.7 points) outcomes without any donor-site morbidities were observed. Twenty-three (65.7%) patients were satisfied or very satisfied with the surgical treatment. Fourteen (40.0%) and 25 (71.4%) patients had no or minor limitations in their athletic and working performance, respectively. A significant correlation between the MOCART and the FAOS Sport and Recreational activities subscale was found (rs, 0.491; p = 0.033). Six (17.1%) patients met the criteria for clinical failure an average of 12.2 ± 6.6 years after AOT. Survival analysis demonstrated a mean estimated time of survival of 21.3 years (95% CI [19.55, 22.96]) and a 20-year survival rate of 77.9%. CONCLUSION: Autologous osteochondral transplantation to treat OLT achieves high patient satisfaction and favorable PROs with a 20-year survival rate of almost 80%. Given the high clinical efficacy of AOT, this procedure can be recommended as a safe and promising technique for the long-term therapy of OLT. LEVEL OF EVIDENCE: Level IV.

Derotational distal femoral osteotomy for patients with recurrent patellar instability and increased femoral antetorsion improves knee function and adequately treats both torsional and valgus malalignment.

PURPOSE: The aim of the study was to evaluate the functional and radiological outcome following derotational distal femoral osteotomy (D-DFO) in patients with high-grade patellofemoral instability (PFI) and an associated increased femoral antetorsion (FA). It was hypothesized that D-DFO would lead to a good functional and radiological outcome, and that both torsional and coronal malalignment could be normalized. METHODS: Patients that underwent D-DFO between 06/2011 and 12/2018 for high-grade PFI with an increased FA (> 20°) were included. Patient-reported outcome measures (Visual Analog Scale [VAS] for pain, Kujala score, Lysholm score, International Knee Documentation Committee subjective knee form [IKDC], and Tegner Activity Scale [TAS]) were evaluated pre- and minimum 24 months postoperatively. Magnetic resonance imaging of the lower extremity and weight-bearing whole-leg anteroposterior radiographs were conducted pre- and postoperatively. The change in FA, coronal limb alignment, and PROMs were tested for statistical significance. RESULTS: In total, 27 patients (30 knees) were included. The D-DFO aimed to only correct FA (Group 1) or to additionally perform a varization (Group 2) in 14 cases each. In the remaining two cases, double-level osteotomies were performed to correct additional tibial deformities. In 25 cases (83.3%), concomitant procedures also addressing patellofemoral instability were performed. At follow-up (38.0 months [25-75% interquartile range 31.8-52.5 months]), a significant reduction in pain (VAS for pain: 2.0 [1.0-5.0] vs. 0 [0-1.0], p < 0.05), significant improvement in knee function (Kujala Score: 55.6 ± SD 13.6 vs. 80.3 ± 16.7, p < 0.05; Lysholm Score: 58.6 ± 17.4 vs. 79.5 ± 16.6, p < 0.05; IKDC: 54.6 ± 18.7 vs. 74.1 ± 15.0, p < 0.05), and an increase in sporting activity (TAS: 3.0 [3.0-4.0] vs. 4.0 [3.0-5.0], p = n.s.) were reported. Femoral antetorsion was significantly reduced (28.2 ± 6.4° vs. 13.6 ± 5.2°, p < 0.05). A significant varization was observed in Group 2 (2.4 ± 1.2° valgus vs. 0.3 ± 2.4° valgus; p < 0.05). In one case, patellar redislocation occurred 70 months postoperatively. CONCLUSION: In patients with PFI and an associated increased FA, D-DFO achieved a significant reduction in pain, an improvement of subjective knee function, as well as an adequate correction of torsional and coronal alignment. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Management after acute rupture of the anterior cruciate ligament (ACL). Part 1: ACL reconstruction has a protective effect on secondary meniscus and cartilage lesions.

PURPOSE: The aim of this consensus project was to validate which endogenous and exogenous factors contribute to the development of post-traumatic osteoarthritis and to what extent ACL (anterior cruciate ligament) reconstruction can prevent secondary damage to the knee joint. Based on these findings, an algorithm for the management after ACL rupture should be established. METHODS: The consensus project was initiated by the Ligament Injuries Committee of the German Knee Society (Deutsche Kniegesellschaft, DKG). A modified Delphi process was used to answer scientific questions. This process was based on key topic complexes previously formed during an initial face-to-face meeting of the steering group with the expert group. For each key topic, a comprehensive review of available literature was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Consensus was defined a-priori as eighty percent agreement. RESULTS: Of the 17 final statements, 15 achieved consensus, and 2 have not reached consensus. Results of the consensus were summarized in an algorithm for the management after ACL rupture (infographic/Fig. 2). CONCLUSION: This consensus process has shown that the development of post-traumatic osteoarthritis is a complex multifactorial process. Exogenous (primary and secondary meniscus lesions) and endogenous factors (varus deformity) play a decisive role. Due to the complex interplay of these factors, an ACL reconstruction cannot always halt post-traumatic osteoarthritis of the knee. However, there is evidence that ACL reconstruction can prevent secondary joint damage such as meniscus lesions and that the success of meniscus repair is higher with simultaneous ACL reconstruction. Therefore, we recommend ACL reconstruction in case of a combined injury of the ACL and a meniscus lesion which is suitable for repair. LEVEL OF EVIDENCE: Level V.

Management after acute injury of the anterior cruciate ligament (ACL), part 2: management of the ACL-injured patient.

PURPOSE: The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process. METHODS: For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient. LEVEL OF EVIDENCE: Level V.

Iatrogenic instability of the acromioclavicular joint leads to ongoing impairment of shoulder function even following secondary surgical stabilization.

PURPOSE: Iatrogenic instability of the acromioclavicular joint (ACJ) following distal clavicle excision (DCE) represents an infrequent pathology. Revision surgery to restore ACJ stability and alleviate concomitant pain is challenging due to altered anatomic relationships. The purpose of this study was to evaluate the used salvage techniques and postoperative functional and radiological outcomes in retrospectively identify patients with a painful ACJ following DCE. We hypothesized that iatrogenic instability leads to ongoing impairment of shoulder function despite secondary surgical stabilization. METHODS: 9 patients with a painful ACJ after DCE (6 men, 3 women, 43.3 ± 9.4 years) were followed up at a minimum of 36 months after revision surgery. Besides range of motion (ROM), strength and function were evaluated with validated evaluation tools including the Constant score and the DASH score (Disability of the Arm, Shoulder and Hand questionnaire), specific AC Score (SACS), Nottingham Clavicle Score (NCS), Taft score and Acromioclavicular Joint Instability Score (AJI). Additionally, postoperative X-rays were compared to the unaffected side, measuring the coracoclavicular (CC) and acromioclavicular (AC) distance. RESULTS: At follow-up survey (55.8 ± 18.8 months) all patients but one demonstrated clinical ACJ stability after arthroscopically assisted anatomical ACJ reconstruction with an autologous hamstring graft. Reconstruction techniques were dependent on the direction of instability. The functional results demonstrated moderate shoulder and ACJ scores with a Constant Score of 77.3 ± 15.4, DASH-score of 51.2 ± 23.4, SACS 32.6 ± 23.8, NCS 77.8 ± 14.2, AJI 75 ± 14.7 points and Taft Score 7.6 ± 3.4 points. All patients stated they would undergo the revision surgery again. Mean postoperative CC-distance (8.3 ± 2.8 mm) did not differ significantly from the contralateral side (8.5 ± 1.6 mm) (p > 0,05). However, the mean AC distance was significantly greater with 16.5 ± 5.8 mm compared to the contralateral side (3.5 ± 1.9 mm) (p = 0.012). CONCLUSION: Symptomatic iatrogenic ACJ instability following DCE is rare. Arthroscopically assisted revision surgery with an autologous hamstring graft improved ACJ stability in eight out of nine cases (88.9%). However, the functional scores showed ongoing impairment of shoulder function and a relatively high overall complication rate (33.3%). Therefore, this study underlines the importance of precise preoperative indication and planning and, especially, the preservation of ACJ stability when performing AC joint resection procedures. LEVEL OF EVIDENCE: Case series, LEVEL IV.

Anatomic repair and ligament bracing as an alternative treatment option for acute combined PCL injuries involving the posteromedial or posterolateral corner-results of a multicentre study.

INTRODUCTION: Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. MATERIALS & METHODS: N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. RESULTS: N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). CONCLUSIONS: One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. LEVEL OF EVIDENCE: Level II.

Clinical outcome and healing rate after meniscal bucket handle tear repair.

BACKGROUND: Reports combining patient-reported outcome measures, clinical evaluation, and radiographic assessment of postoperative healing after arthroscopic repair of bucket-handle meniscal tears (BHMT) are scarce. METHODS: Patients who underwent arthroscopic repair for acute traumatic BHMTs between October 2011 and March 2016 with a minimum follow-up of two years were included. Postoperative outcome scores comprised the International Knee Documentation Society Score (IKDC), Lysholm score, Tegner activity score (TAS), and visual analog scale (VAS) for pain. Clinical meniscal healing failure was assessed according to Barrett's criteria. Side-to-side difference in knee laxity was measured using KT-2000. Radiographic healing was assessed by 3-Tesla magnetic resonance imaging (MRI) and classified according to Henning's criteria at final follow-up. RESULTS: Forty patients with a mean age of 32.0 ± 11.5 years were available for follow-up after 51.8 ± 14.3 months. Revision surgery by means of arthroscopic partial meniscectomy was performed in four patients (10%) prior to the follow-up visit. The clinical healing rate was 83.3% at final follow-up. Mean IKDC score was 82.8 ± 13.8 and Lysholm score was 77.4 ± 24.8. Of all patients, 87.5% reached or exceeded the patient-acceptable symptomatic state (PASS) criteria for the IKDC score at final follow-up. The median TAS was 6 and VAS for pain was 0.46 ± 0.9. Side-to-side difference in knee laxity was higher in patients with concomitant ACL reconstruction (2.1 ± 2.7 mm) compared to isolated BHMTs (1.0 ± 2.0 mm). MR examination showed 69.4% healed, 25.0% partially healed, and 5.6% unhealed menisci. CONCLUSION: Patients who underwent repair for acute traumatic BHMTs achieved good to excellent clinical outcome along with a high rate of meniscal healing at a minimum follow-up of two years. Clinical and radiological healing rates were similarly satisfactory and most patients exceeded the PASS criteria for the IKDC score. Patients were able to reach a high postoperative activity level. LEVEL OF EVIDENCE: Case Series; IV.

Anterior cruciate ligament autograft maturation on sequential postoperative MRI is not correlated with clinical outcome and anterior knee stability.

PURPOSE: Magnetic resonance imaging (MRI) signal intensity is correlated to structural postoperative changes of the anterior cruciate ligament (ACL) autograft. The purpose of this study was to investigate the ACL autograft maturation process via MRI over 2 years postoperatively, compare it to a native ACL signal and correlate the results with clinical outcome, return to preinjury sports levels, and knee laxity measurements. METHODS: ACL autograft signal intensity was measured in 17 male patients (age, 28.3 ± 7.0 years) who underwent ACL reconstruction with hamstring autograft at 6 weeks, 3-, 6-, 12-, and 24 months postoperatively by 3 Tesla MRI. Controls with an intact ACL served as control group (22 males, 8 females; age, 26.7 ± 6.8 years). An ACL/PCL ratio (APR) and ACL/muscle ratio (AMR) was calculated to normalize signals to soft tissue signal. APR and AMR were compared across time and to native ACL signal. Clinical outcome scores (IKDC, Lysholm), return to preinjury sports levels (Tegner activity scale), and knee laxity measurement (KT-1000) were obtained and correlated to APR and AMR at the respective time points. RESULTS: The APR and AMR of the ACL graft changed significantly from the lowest values at 6 weeks to reach the highest intensity after 6 months (p < 0.001). Then, the APR and AMR were significantly different from a native ACL 6 months after surgery (p < 0.01) but approached the APR and AMR of the native ACL at 1- and 2 years after surgery (p < 0.05). The APR changed significantly during the first 2 years postoperatively in the proximal (p < 0.001), mid-substance (p < 0.001), and distal (p < 0.01) intraarticular portion of the ACL autograft. A hypo-intense ACL MRI signal was associated with return to the preinjury sports level (p < 0.05). No correlation was found between ACL MRI graft signal and clinical outcome scores or KT-1000 measurements. CONCLUSION: ACL grafts undergo a continuous maturation process in the first 2 years after surgery. The ACL graft signals became hyper-intense 6 months postoperatively and approximated the signal of a native intact ACL at 12- and 24 months. Patients with a hypo-intense ACL graft signal at 2 years follow-up were more likely to return to preinjury sports levels. The results of the present study provide a template for monitoring the normal ACL maturation process via MRI in case of prolonged clinical symptoms. However, subjective outcome and clinical examination of knee laxity remain important to assess the treatment success and to allow to return to sports. LEVEL OF EVIDENCE: III.

Autologous chondrocyte implantation combined with anterior cruciate ligament reconstruction: similar short-term results in comparison with isolated cartilage repair in ligament intact joints.

PURPOSE: Both acute ruptures of the anterior cruciate ligament (ACL) as well as chronic ACL insufficiency show a high association with focal cartilage defects of the knee. However, the results after combined ACL reconstruction and cartilage repair are not well investigated. The aim of the present study was to investigate the short-term outcomes after autologous chondrocyte implantation (ACI) in combination with ACL reconstruction and to compare the results with patients who underwent isolated ACI in ligament intact knees. METHODS: All patients who were registered in the German Cartilage Registry with ACI for focal cartilage defects in the knee joint in combination with ACL reconstruction and who completed the 24 month follow-up were included in the study group. A matched-pair procedure according to gender, defect location, defect size, and age was used to create a control group of patients with isolated ACI in ACL intact joints. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the numeric analog scale for pain (NAS) were used to assess the preoperative state as well as the clinical outcomes 12 and 24 months after surgery. RESULTS: A total of 34 patients were included in both the study group (age mean 33.3 ± SD 8.8 years) and the control group (33.6 ± 8.4 years) with a median defect size of 466 (25%-75% IQR 375-600) mm2 and 425 (IQR 375-600) mm2, respectively. In comparison with the preoperative state (median 67, IQR 52-75), the study group showed a significant increase of the total KOOS after 12 months (78, IQR 70-86; p = 0.014) and after 24 months (81, IQR 70-84; p = 0.001). The NAS for pain did not change significantly in the postoperative course. In comparison with the control group there was no significant difference for the total KOOS neither preoperative (control group median 67, IQR 52-73) nor at any postoperative time point (12 months: 82, IQR 67-93; 24 months: 81, IQR 71-91). CONCLUSION: The clinical short-term outcomes after ACI at the knee joint in combination with ACL reconstruction are good and similar to the results after isolated ACI in ligament intact knees. LEVEL OF EVIDENCE: III.

Ultrasound-based examination of the medial ligament complex shows gender- and age-related differences in laxity.

PURPOSE: Ultrasound (US) examination of the medial joint space of the knee has played a subordinate diagnostic role up till now. The purpose of the present study was to describe mean values of medial joint width and to investigate the impact of gender, age, and body mass index (BMI) on medial joint laxity in healthy knees using modern, dynamic US in a standardized fashion in unloaded and standardized loaded conditions. METHODS: A total of 65 subjects with 79 healthy knees were enrolled in this study. All volunteers underwent clinical examination of the knee. The medial knee joint width was determined using US in a supine position at 0° and 30° of knee flexion in unloaded and standardized loaded (= 15 Dekanewton, daN) conditions using a specific device. Mean values were described and correlations between medial knee joint width and gender, age, and BMI were assessed. RESULTS: Thirty-two females and 33 males were enrolled in this study. The mean medial joint width in 0° unloaded was 5.7 ± 1.2 mm and 7.4 ± 1.4 mm loaded. In 30° of knee flexion, the mean medial joint width was 6.1 ± 1.1 mm unloaded and 7.8 ± 1.2 mm loaded. The average change between unloaded and loaded conditions in 0° was 1.7 ± 1.0 mm and in 30° 1.7 ± 0.9 mm. A significant difference between genders was evident for medial joint width in 0° and 30° of flexion in unloaded and loaded conditions (p < 0.05). With rising age, a significant increased change of medial joint space width between unloaded and loaded conditions could be demonstrated in 0° (p = 0.032). No significant correlation between BMI and medial joint width in US could be found. CONCLUSION: Mean values of medial joint width in unloaded and standardized loaded conditions using a fixation device could be demonstrated. Based on the results of this study, medial knee joint width in US is gender- and age-related in healthy knees. These present data may be useful for evaluating patients with acute or chronic pathologies to the medial side of the knee. LEVEL OF EVIDENCE: III.

Dynamic Q-angle is increased in patients with chronic patellofemoral instability and correlates positively with femoral torsion.

PURPOSE: The purpose of the study was to evaluate the frontal gait patterns in patients with chronic patellofemoral instability compared to healthy controls. The hypothesis was that internal-rotation-adduction moment of the knee as altered dynamic Q-angle is evident in patients and correlates positively with increased femoral torsion. METHODS: Thirty-five patients with symptomatic recurrent patellofemoral instability requiring surgical treatment were matched for average age, sex, and body mass index with 15 healthy controls (30 knees). Several clinical and radiographic measurements were taken from each participant: internal and external rotation (hipIR, hipER), Q-angle, tubercle sulcus angle (TS-angle), femoral antetorsion (femAT), tibial tubercle-trochlear groove (TT-TG) distance, and frontal leg axis. Additionally, three frontal gait patterns were defined and recorded: (1) internal-rotation-adduction moment of the knee during normal walking, (2) dynamic valgus of the knee, and (3) Trendelenburg's sign in a single-leg squat. Randomized videography was evaluated by three independent blinded observers. Statistical analysis was performed using regression models and comparisons of gait patterns and clinical and radiological measurements. Furthermore, observer reliability was correlated to gradings of radiological parameters. RESULTS: Patients showed altered dynamic Q-angle gait pattern during normal walking (p < 0.001) compared to healthy controls (interrater kappa = 0.61), whereas highest observer agreement was reported if femAT was greater than 20° (kappa = 0.85). Logistic regression model revealed higher femAT (18.2° ± 12.5 versus 11.9° ± 7.0 (p = 0.004) as a significant variable, as well as lower TT-TG distance (23.6 mm ± 2.8 vs. 16.6 mm ± 4.9, p = 0.004) on evident dynamic Q-angle gait pattern. Dynamic valgus in a single-leg squat was observed significantly more often in patients (p < 0.001) compared to controls (interrater kappa = 0.7). However, besides the static measured Q-angle as the only significant variable on evident dynamic valgus pattern (13.6° ± 4.6 vs. 10.3° ± 5.2, p = 0.003), no radiological parameter was detected to correlate significantly with dynamic valgus and Trendelenburg's sign (n.s.). CONCLUSIONS: Clinical detection of pathologic torsion and bony alignment may be difficult in patients with patellofemoral instability. The present study demonstrated that dynamic Q-angle gait pattern is significantly altered in patients with chronic patellofemoral instability compared to healthy controls. Moreover, dynamic Q-angle correlates positively with higher femoral torsion and negatively with higher TT-TG distance. Therefore, clinical and radiological assessment of maltorsion should be added to the standard diagnostic workup in cases of patellofemoral instability. LEVEL OF EVIDENCE: Level II.

[Female doctors in orthopedics and trauma surgery in Germany: a current status quo]. / Ärztinnen in der Orthopädie und Unfallchirurgie in Deutschland: ein aktueller Status quo.

BACKGROUND: Gender-specific differences in the workplace in general and in the field of orthopedics and trauma surgery in particular are still clearly identifiable, and are becoming more and more pronounced in the social consciousness. OBJECTIVE: Analysis of the gender-specific development in the specialist field of orthopedics and trauma surgery in Germany over the past 15 years and a survey of the status quo. METHODS: Assessment of the development of female graduates in the study of human medicine, the proportion of women in accredited and clinical care and the gender-specific acquisition of an additional orthopedic/trauma surgical title. Evaluation of gender-specific numbers of members or participants in the relevant professional associations and the largest German conferences on orthopedics and trauma surgery, as well as the habilitation figures in the field of orthopedics. RESULTS AND DISCUSSION: The proportion of female doctors in various fields of orthopedics and trauma surgery in the clinic and in science is increasing. There is still a clear discrepancy in leading positions in clinics, in the acquisition of an additional title, and on the boards of professional associations. In some fields, such as pediatric and hand/foot/ankle surgery, the proportion of women is higher than in other sub-areas of orthopedics and trauma surgery.

Patellar sleeve avulsion fracture in a patient with Sinding-Larsen-Johansson syndrome: a case report.

BACKGROUND: Patellar sleeve avulsion (PSA) fractures are rare injuries that occur in in skeletally immature patients. Initial diagnosis is key to a successful outcome, as these injuries are easily overlooked on plain radiographs with poor results well documented from delayed management. High index of suspicion from the mechanism of injury, thorough clinical examination and Magnetic Resonance Imaging (MRI) help to avoid misdiagnosis. CASE PRESENTATION: The case of a 12-year-old male athlete with an acute PSA after a conservative treatment of a SLJ syndrome is described. The patient was referred to our clinic due to severe pain and loss of function after performing a high jump. Plain radiographs (X-ray) and MRI confirmed an inferior pole PSA which was fixed with double trans osseous ultra-high strength tapes. At the 3-month follow- up visit the patient was able to ambulate brace free. At 2-years follow up the patient was able to play soccer and ice hockey. To our knowledge, there are no case reports of inferior pole PSA with prior SLJ syndrome described in literature. CONCLUSIONS: Early clinical suspicion and distinguishing this PSA from other enchondral ossification disorders around the knee is critical to avoid misdiagnosis. Whether SLJ syndrome increases the risk of sustaining a PSA is still not clear. Trans osseous fixation with suture tapes leads to good functional results in a young athlete with inferior pole PSA.

Promising clinical and magnetic resonance imaging results after internal bracing of acute posterior cruciate ligament lesions in multiple injured knees.

PURPOSE: The purpose of this study was to evaluate the clinical and radiological outcomes of acute posterior cruciate ligament (PCL) lesions in multiple injured knees that were surgically treated with internal bracing. METHODS: Acute complete PCL lesions in multiple injured knees with subsequent internal-bracing treatment within 21 days between 2014 and 2016 were eligible for inclusion. At final follow-up, patients were assessed with Tegner, Lysholm, and IKDC scores. PCL stability and healing were verified with KT-2000, stress radiography and magnetic resonance imaging (MRI). RESULTS: Fourteen patients [mean age 37.4 (± 17.8; SD) years] were evaluated after a mean follow-up of 19.9 (± 7.7; SD) months. Thirteen patients suffered complete lesions of the PCL with concomitant ligamentous injuries (Schenck I: six cases, Schenck III M: five cases, Schenck IV N: one case, Schenck V: one case). Median Tegner, mean Lysholm and mean IKDC scores at follow-up were 4 (2-7; interquartile range), 69.1 (± 16.6; SD) and 68.9 (± 18.1; SD) respectively. Posterior translation averaged 5.8 (± 2.2; SD) mm with the KT 2000 and stress radiography showed a mean posterior tibial translation of 5.5 (± 4.1; SD) mm in the side to side comparison. MRI showed adequate PCL healing. CONCLUSIONS: Internal bracing as treatment for acute PCL ruptures in multiple injured knees showed adequate restoration of posterior tibial translation in a single-centre study including 14 cases. LEVEL OF EVIDENCE: IV.

Varus alignment increases medial meniscus extrusion and peak contact pressure: a biomechanical study.

PURPOSE: Assessment of medial meniscus extrusion (MME) has become increasingly popular in clinical practice to evaluate the dynamic meniscus function and diagnose meniscus pathologies. The purpose of this biomechanical study was to investigate the correlation between MME and the changes in joint contact pressure in varus and valgus alignment. It was hypothesized that varus alignment would result in significantly higher MME along with a higher joint contact pressure in the medial compartment. METHODS: Eight fresh-frozen human cadaveric knees were axially loaded, with a 750 N compressive load, in full extension with the mechanical axis shifted to intersect the tibial plateau at 30% and 40% (varus), 50% (neutral), 60% and 70% (valgus) of its width (TPW). Tibiofemoral peak contact pressure (PCP), mean contact pressure (MCP) and contact area (CA) were determined using pressure-sensitive films. MME was obtained via ultrasound at maximum load. RESULTS: MME was significantly increased from valgus (1.32 ± 0.22 mm) to varus alignment (3.16 ± 0.24 mm; p < 0.001). Peak contact pressure at 30% TPW varus alignment was significantly higher compared to 60% TPW valgus (p = 0.018) and 70% TPW valgus (p < 0.01). MME significantly correlated with PCP (r = 0.56; p < 0.001) and MCP (r = 0.47, p < 0.01) but not with CA (r = 0.23; n.s.). CONCLUSION: MME was significantly increased in varus alignment, compared to neutral or valgus alignment, with an intact medial meniscus. It was also significantly correlated with PCP and MCP within the medial compartment. However, valgus malalignment and neutral axis resulted in reduced MME and contact pressure. Lower limb alignment must be taken into account while assessing MME in clinical practice. LEVEL OF EVIDENCE: Controlled laboratory study.

Varus alignment aggravates tibiofemoral contact pressure rise after sequential medial meniscus resection.

PURPOSE: Arthroscopic partial meniscectomy of medial meniscus tears and varus alignment are considered independent risk factors for increased medial compartment load, thus contributing to the development of medial osteoarthritis. The purpose of this biomechanical study was to investigate the effect of lower limb alignment on contact pressure and contact area in the knee joint following sequential medial meniscus resection. It was hypothesized that a meniscal resection of 50% would lead to a significant overload of the medial compartment in varus alignment. METHODS: Eight fresh-frozen human cadaveric knees were axially loaded with a 750 N compressive force in full extension with the mechanical axis rotated to intersect the tibia plateau at 30%, 40%, 50%, 60% and 70% of its width. Tibiofemoral mean contact pressure (MCP), peak contact pressure (PCP), and contact area (CA) of the medial and lateral compartment were measured separately using pressure-sensitive films (K-Scan 4000, Tekscan) in four different meniscal conditions, respectively, intact, 50% resection, 75% resection, and total meniscectomy. RESULTS: Medial MCP was significantly increased when comparing the intact meniscus to each meniscal resection in all tested alignments (p < 0.05). Following meniscal resection of 50%, MCP was significantly higher with greater varus alignment compared to valgus alignment (p < 0.05). Similarly, medial PCP was higher at varus alignment compared to valgus alignment (p < 0.05). Further resection to 75% and 100% of the meniscus resulted in a significantly higher medial PCP at 30% of tibia plateau width compared to all other alignments (p < 0.05). Medial CA of the intact meniscus decreased significantly after 50%, 75% and 100% meniscal resection in all alignments (p < 0.05). Lateral joint pressure was not significantly increased by greater valgus alignment. CONCLUSION: Lower limb alignment and the extent of medial meniscal resection significantly affect tibiofemoral contact pressure. Combined varus alignment and medial meniscal resection increased MCP and PCP within the medial compartment, whereas valgus alignment prevented medial overload. As a clinical consequence, lower limb alignment should be considered in the treatment of patients undergoing arthroscopic partial meniscectomy with concomitant varus alignment. In patients presenting with ongoing medial joint tenderness and effusion, realignment osteotomy can be a surgical technique to unload the medial compartment.