OBJECTIVE:Improvement of flexion and thereby restoration of function of the knee joint as well as pain reduction by proximalization of the tibial tuberosity in combination with arthrolysis and release of the patellar retinaculum. INDICATIONS:Salvage surgery if conservative or arthroscopic treatment for a patella baja (Canton-Deschamps index < 0.6) has failed, especially in the case of mechanical and pain-related limitation of mobility. The timing for the surgery is crucial; surgery should only be performed after the end of the inflammatory phase and fibrosis of the patella ligament is complete. CONTRAINDICATIONS:Possible conservative and arthroscopic therapy attempts, local infection, pseudarthrosis, bone defects of the patella, fracture in the area of the tuberosity, active inflammatory process. SURGICAL TECHNIQUE:Median longitudinal incision. Combined medial and lateral arthrotomy alongside the patellar tendon. Wedge-shaped tuberosity osteotomy over approximately 7 cm. The patella is thereafter reflected proximally to expose the entire knee joint. Extensive open arthrolysis especially of the superior recess and release of the retinaculum. Proximalized refixation of the tuberosity with at least two screws, depending on the preoperative planning and intraoperative movement control. If necessary, lengthening of the medial and lateral retinaculum to completely close the joint. POSTOPERATIVE MANAGEMENT:Postoperative (post-OP) week 1-6: partial weight bearing 20 kg, knee brace, continuous passive motion (CPM) training, limitation of the range of motion (ROM) to flexion/extension: 90°/0°/0°. Post-OP week 7: additional load of 20 kg per week, free ROM. RESULTS:The authors followed a series of 7 patients with proximalization of the tibial tuberosity in symptomatic patella baja. The authors recorded pre- and postoperative patient-reported outcome measures with an average follow-up of 3.0 ± 2.6 years (range 0.6-7.6 years). The patients were 43 ± 11 years old (6 women, 1 men). There was a significant improvement in the 2000 International Knee Documentation Committee (IKDC)-subjective score (pre-OP: 40 ± 17 vs. post-OP: 72 ± 10; p = 0.011) and in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscore for activities of daily living (pre-OP: 20 ± 23 vs. post-OP: 60 ± 20; p = 0.014). The authors were also able to identify a trend towards improvement, particularly in the Kujala score and the KOOS subscores for pain and physical activity; however no significant improvements were observed. These results make it clear that the proximalization of the patellar tuberosity can improve the subjective outcome in symptomatic patella baja.

Arthroscopically assisted techniques for acromioclavicular joint reconstruction have increasingly been used over the past 15 years. Long-term results are lacking. Patients will continue to show good clinical function and sustained anatomic reduction at long-term follow-up. Cohort study; Level of evidence, 3. Twenty patients (67%) with a known endpoint were followed up at a mean of 15 years (range, 14-16 years) postoperatively. Twelve patients (60%) had Rockwood type 5, 6 (30%) type 4, and 2 (10%) type 3 injuries. Clinical evaluation included the Simple Shoulder Test, Constant score, pain score of 0 to 10, and satisfaction graded 0 (not satisfied) to 4 (very satisfied). Fourteen patients had complete outcome scores at the final follow-up. Nine patients underwent radiographic examination and were assessed for coracoclavicular distance, posterior acromioclavicular subluxation, arthritis, ossification, and hardware displacement by 3 observers. The respective mean preoperative, 2-year, 5-year, and 15-year outcome scores were as follows: 34.5 ± 6.9, 94.3 ± 3.2 (P < .05), 91.5 ± 4.7, and 91.2 ± 4.8 (P > .05) for the Constant score; 2.8 ± 2.1, 12.0 ± 0 (P < .05), 11.8 ± 0.5, and 11.7 ± 0.4 (P > .05) for Simple Shoulder Test; and 4.5 ± 1.9, 0.3 ± 0.5 (P < .05), 0.3 ± 0.6, and 0.4 ± 0.8 (P > .05) for pain. The 2-year satisfaction was 4.0 ± 0; the 5-year score, 3.8 ± 0.5; and the 15-year score, 3.7 ± 0.4 (P > .05). Coracoclavicular distance (mm) decreased from 20.5 ± 4.6 preoperatively to 10.5 ± 3.6 at 2 years (P < .05), 11 ± 3.2 at 5 years, and 11.3 ± 4.3 at 15 years of follow-up (P > .05). Acromioclavicular posterior subluxation remained unchanged (P > .05). Six patients (67%) had asymptomatic ossification of the coracoclavicular ligaments; their Constant score was 93.3. One patient developed acromioclavicular arthritis radiologically with clinical correlation but did not require further surgery. Three patients (10%) underwent revision stabilization within 3 months, 1 for infection and 2 for mechanical failure. Fifteen years postoperatively, good clinical results persisted and anatomic reduction was overall maintained, often with asymptomatic ossification of the coracoclavicular ligaments.

PURPOSE:To perform an updated systematic review of the biomechanical characteristics investigating the contributions of the anterolateral ligament (ALL) complex to rotational and anterior knee stability in anterior cruciate ligament-intact (ACLI), anterior cruciate ligament-deficient (ACLD), and ACL-reconstructed knees. METHODS:Medline, Embase, Scopus, and Google Scholar were screened for studies from 2012 to 2024. Biomechanical laboratory cadaver studies were included if they described biomechanical characteristics in ACLI, ACLD, or ACL-reconstructed with (ALLR) or without ALL-reconstruction (ALLD). Studies examining other anatomical structures, such as the iliotibial band and Kaplan fibers, and alternative reconstruction techniques, such as lateral extra-articular tenodesis, were excluded. Critical Appraisal Skills Programme checklist for qualitative research and the Biomechanics Objective, Basic Science Quality Assessment Tool scale, were used for study quality assessment. Heterogeneity within and between studies was evaluated using the I2 statistic. Publication bias was examined using funnel plots and the Egger test. RESULTS:Twenty-two studies were included in the analysis. Critical Appraisal Skills Programme assessment deemed 21 of these studies to be valuable. Biomechanics Objective, Basic Science Quality Assessment Tool evaluated, 9 studies were as moderate quality, 8 as fair quality, and 5 as poor quality. The mean load to failure varied between 49 N and 319.8 N, with a pooled mean of 171.9 N. Stiffness values ranged from 2.6 to 41.9 N/mm, yielding a pooled mean of 21.46 N/mm. Comparisons of load displacement did not reveal significant differences across the following groups for both anterior tibial translation and internal rotation for all comparisons. CONCLUSIONS:This systematic review did not find conclusive evidence that the ALL plays a significant role in limiting anterior tibial translation or internal rotation stability in either ACLI or ACLR knees at point zero during biomechanical testing of cadaver specimens. CLINICAL RELEVANCE:Biomechanical laboratory studies conducted at time zero suggest that the added benefit of combining ALLR with ACLR remains uncertain. When ACLR sufficiently restores knee stability, additional procedures may not always be necessary.

PURPOSE:The main goal was to perform a modified Delphi process with the Ligament Injuries Committee of the German Knee Society (DKG) to structure and optimize the management of isolated posterior cruciate ligament (PCL) injuries. METHODS:A structured modified Delphi approach was used to develop an expert statement. Steering group formulated an initial questionnaire and distributed it to 15 experienced knee surgeons (male/female 13/2, mean age 45 ± 5 years) of the working group in Round 1. Thirty-one statements covering five thematic topics were then derived from the responses and comprehensive literature search (Medline, Scopus and Cochrane) using variations of different search terms (literature group). The statements underwent two rating cycles by the working group, using a 5-point Likert scale in Round 2 and as a binary 'agree/disagree' in the final third round. Levels of evidence were assigned to each statement using standardized A-E and GRADE grading systems based on the available data. RESULTS:High agreement (≥80%) was achieved for 24 of the 31 statements (range, 83%-100%), whereas for 7 agreement was <80% (range 63%-74%). The highest levels of agreement were reached for imaging modalities, treatment of PCL tibial avulsions, and preservation of native PCL fibres in reconstruction techniques, whereas the greatest divergence was observed regarding the role of leg axis and slope analyses and indications for corrective osteotomies, use of augmentation in reconstruction and post-operative rehabilitation protocols. The available level of evidence across studies in the literature was predominantly low to moderate. Of the 31 statements, 17 were graded as expert opinion (E, GRADE: very low), 12 as case series (C; GRADE: low), and only 2 achieved higher levels of evidence (B2, GRADE: moderate). CONCLUSION:By providing structured treatment protocols, this Delphi-based structured expert statement can support clinicians in day-to-day decision-making and ultimately improve patient care and outcomes. STUDY DESIGN:Expert survey. LEVEL OF EVIDENCE:Level V.

BACKGROUND:To quantify the five-year injury incidence and to identify risk factors and common injury patterns in beach handball athletes. It was hypothesized that there would be a low incidence of injuries with identifiable risk and preventative factors. METHODS:An online survey was conducted among active beach handball athletes from 08-09/2022. Demographics, activity level and data on acute and overuse injuries over the past five years were collected. Risk factor analyses were performed for acute and overuse injuries. RESULTS:A total of 651 athletes (54% male) were included. No injury was reported by 489 (75%) athletes and 162 (25%) athletes reported at least one injury with a total of 174 injuries (102 acute, 72 overuse). The injury incidence was 53.5 injuries per 1,000 athletes per year. The lower extremity was most commonly affected. Older age, the number of tournaments per year and the number of months playing beach handball per year were risk factors for injury. Playing as shooting specialist reduced the risk. Of the injuries, 14 (8%) were treated surgically. Most athletes returned to full beach handball within two months (acute: 70%; overuse: 80%). CONCLUSION:Injury incidence was low among beach handball athletes. Injuries most commonly affected the lower extremity. Older age, number of months playing beach handball and number of tournaments were risk factors for injury. Only 8% of the injuries required surgery. Return to sport outcomes was favorable. This implies a potential for targeted injury prevention strategies and the reassurance of low injury burden in beach handball. LEVEL OF EVIDENCE:Level III (retrospective comparative study).

Biologische Knorpelersatzverfahren weisen teilweise hohe Versagensraten auf und sind insbesondere bei negativen Kontextfaktoren wie dem Alter oder vorrausgegangenem Knorpeleingriff mit schlechten Ergebnissen verbunden. Teilprothesen im Sinne von Mini-Implantaten, welche den Defekt lokal ausfüllen sollen und gleichzeitig den Knochen- wie auch Knorpeldefekt behandeln, können eine gute Alternative darstellen. Die Korrektur einer Achsabweichung bzw. eines Malalignements stellt für die erfolgreiche Therapie eine Grundvoraussetzung dar. Therapiealgorithmen können hier in der Entscheidungsfindung helfen.

Background:Although short- to mid-term clinical data of patients undergoing arthroscopic capsulolabral revision repair (ACRR) for recurrent anterior shoulder instability are promising, evidence pertaining to long-term functional, sports- and work-related outcomes is scarce. Purpose/Hypothesis:The purpose was to provide prospectively collected long-term functional outcomes, sports activity, and work ability of patients undergoing ACRR for recurrent anterior shoulder instability. It was hypothesized that patients would maintain significant functional improvement, along with sufficient sports activity and work ability, at a minimum follow-up of 20 years. Study Design:Case Series; Level of Evidence 4. Methods:Patients who underwent ACRR between September 1998 and August 2003 and had a minimum follow-up of 20 years were analyzed. Functional outcome measures included the Rowe and Constant-Murley (CM) scores, as well as the visual analog scale (VAS) for pain, which were collected preoperatively, at short-term follow-up (a minimum of 2 years), and at a minimum final follow-up of 20 years. The Single Assessment Numeric Evaluation and Simple Shoulder Test (SST) scores were only collected at the final follow-up. Return to sports and work-including sports and work level and discipline-were evaluated using a custom sports and work ability assessment tool. Results:A total of 29 patients (mean age at surgery, 28.6 ± 9.8 years) were included in the study, with a mean follow-up of 21.1 ± 1.5 years (range, 20-24 years). The rate of recurrent instability was 27.6% (n = 8), while 10.3% (n = 3) underwent revision surgery. In those without recurrent instability, the Rowe and CM scores showed significant improvements at both the minimum 2-year and minimum 20-year follow-ups, compared with preoperatively (P < .001, respectively). Neither the CM (87.9 ± 8 vs 83.4 ± 11; P = .055) nor the Rowe (86.7 ± 18.7 vs 86.9 ± 15.8; P = .958) score differed significantly between the minimum 2-year and 20-year follow-ups. At the minimum 20-year follow-up, the VAS pain score was 0.6 ± 1.6 at rest, was 1.1 ± 1.4 during exercise, and the SST (%) was 89.3 ± 13.5. The amount of activity (P = .022) and the subjective shoulder mobility (P = .021) significantly declined from the minimum 2-year to the 20-year follow-up. Conclusion:Patients undergoing ACRR for recurrent anterior shoulder instability had a recurrent instability rate of 27.6% at a minimum 20-year follow-up. Those patients without recurrence maintained significant improvements in functional outcomes and achieved a favorable postoperative sport activity and work ability.

To prospectively evaluate clinical, functional, radiographic, and sports-related short-term outcomes following isolated patellofemoral inlay arthroplasty (PFIA) utilizing an inlay arthroplasty model featuring an enlarged lateral offset. Patients who underwent patellofemoral inlay arthroplasty (PFIA) with the Hemi-CAP® Kahuna Prosthesis (Anika Therapeutics, Franklin, MA, USA) between January 2017 and July 2020 were included in the study and assessed both preoperatively and at a minimum follow-up of 24 months postoperatively. Patient-reported outcomes measures (PROs) included the transformed Western Ontario and McMaster Universities Arthritis Index (WOMAC), Visual Analogue Scale (VAS) for pain, and Tegner Activity Scale. The Kellgren-Lawrence grading scale was used to assess tibiofemoral osteoarthritis (OA) progression. The Caton-Deschamps Index was used to assess differences in pre- to postoperative patellar height. Eighteen patients (19 knees, 86

Die Evidenz zu den langfristigen Ergebnissen von Patienten, die sich einer arthroskopischen weichteiligen Revisionsstabilisierung (AWRS) zur Behandlung einer rezidivierenden anterioren Schulterinstabilität unterziehen, ist limitiert. Ziel der Studie war es, die Langzeitergebnisse von Patienten zu bewerten, die sich einer AWRS zur Behandlung einer rezidivierenden anterioren Schulterinstabilität unterzogen. Die Hypothese war, dass die Patienten auch langfristig eine signifikante funktionelle Verbesserung beibehalten würden. Es wurden Patienten analysiert, die zwischen 09/1998 und 08/2003 eine AWRS erhielten und eine Nachbeobachtungszeit von mindestens 20 Jahren hatten. Funktionelle Ergebnisse wurden anhand der Rowe- und Constant-Murley(CM)-Scores sowie der visuellen Analogskala (VAS) für Schmerzen gemessen und sowohl präoperativ als auch bei einer kurzfristigen Nachuntersuchung (mind. 2 Jahre) sowie bei der abschließenden Nachuntersuchung (mind. 20 Jahre) erhoben. Die Rückkehr zu Sport und Beruf, einschließlich Sport- und Arbeitsniveau sowie Disziplin, wurden ebenfalls erfasst. In die Studie wurden 29 Patienten mit einer durchschnittlichen Nachbeobachtungszeit von 21,1 ± 1,5 Jahren eingeschlossen. Die Rate der Rezidiv-Instabilität betrug 27,6