Bei Kreuzbandverletzungen im Kindes- und Jugendalter handelt es sich neben den rein ligamentären Rupturen häufig um Avulsionsverletzungen. Verletzungsmuster und -mechanismen, das weitere Längenwachstum und psychosoziale Faktoren müssen im Rahmen der Diagnostik und Therapie bedacht werden. Es wurden wachstumsfugenschonende Operationstechniken und Implantate entwickelt. Dieser Artikel beschreibt die wichtigsten Techniken der operativen und nichtoperativen Versorgung, die damit verbundene Nachbehandlung sowie Möglichkeiten der Primär- und Sekundärprävention.

Aim: Anterior cruciate ligament reconstruction (ACLR) in patients over 50 years has traditionally been considered controversial due to concerns about graft failure, limited healing potential, and the risk of degenerative progression. However, with increasing life expectancy and higher physical activity in older adults, the demand for ACLR in this population has grown, and the role of graft selection remains unclear. The aim of this study was to evaluate the influence of graft choice on clinical outcomes, graft survival, and re-rupture rates after ACLR in patients aged 50 years and older. It was hypothesized that (1) ACLR in this population would result in low re-rupture rates and satisfactory functional outcomes, and (2) no significant differences would be observed among different graft types. Evidence review: A systematic literature search of PubMed, Embase, and the Cochrane Library was performed from database inception to July 20, 2025, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included skeletally mature patients ≥50 years undergoing primary ACLR with different grafts (hamstring tendon [HT], bone–patellar tendon–bone [BPTB], quadriceps tendon [QT], allograft, or synthetic). Outcomes of interest included graft re-rupture, Lysholm score, and International Knee Documentation Committee (IKDC) subjective score. Random-effects meta-analyses were conducted to pool results, and subgroup analyses were performed by graft type. Findings: Twenty-one studies including a total of 1093 patients were analyzed. The overall weighted mean age at surgery was 55.88 years (95% confidence interval [CI], 54.6–57.2). The majority of patients underwent HT reconstruction (n = 744–68.1%), followed by QT (n = 142–12.9%), BPTB (n = 81–7.4%), allograft (n = 110–10.1%), and synthetic grafts (ligament augmentation and reconstruction system [LARS]; n = 16–1.5%). The overall re-rupture rate was 0.3% (95% CI, 0.0–1.4), with no statistically significant differences among graft types (p > 0.05), ranging from 0.0% for BPTB/QT to 1.8% for allograft/LARS. The pooled mean Lysholm score was 91.2 (95% CI, 89.5–92.9), and the pooled mean IKDC score was 81.4 (95% CI, 77.9–84.9), showing no statistically significant graft-related differences. Odds ratio analysis confirmed no increased risk of re-rupture across graft types. Conclusions: ACL reconstruction in patients aged 50 years and older is associated with excellent functional outcomes and very low re-rupture rates. No statistically significant differences were observed among graft types. These findings should be interpreted with caution due to limited data for some graft categories and the heterogeneity of the available evidence. Graft selection should be individualized based on patient characteristics and surgeon expertise rather than chronological age. Study design: Systematic review and meta-analysis; level of evidence, III.

PURPOSE:Cyclops syndrome remains a clinically relevant cause of extension deficit after anterior cruciate ligament reconstruction (ACLR), yet its prevention, diagnosis, and management are not standardized. The purpose of this study was to characterize practice patterns, identify areas of consensus and controversy, and derive a clinically applicable management framework based on an international survey of knee surgeons. METHODS:A 69-item online survey was distributed to orthopedic surgeons specialized in knee surgery through multiple international societies. The questionnaire explored five domains: surgeon characteristics, surgical techniques, preventive strategies, diagnostic approaches, and management of cyclops syndrome. Descriptive statistics were used to summarize responses. RESULTS:A total of 250 surgeons from 25 countries completed the survey. Most respondents estimated the incidence of cyclops syndrome between 1% and 5%, with symptomatic presentation typically occurring within 3-6 months after ACLR. Loss of extension greater than 5° was consistently identified as the key clinical finding. Magnetic resonance imaging was the preferred first-line diagnostic modality. Despite heterogeneity in several aspects of care, consistent patterns emerged. Accurate tibial tunnel positioning and restoration of full preoperative knee extension were considered the most critical preventive factors. Initial management was predominantly conservative, with most surgeons advocating an extension-focused rehabilitation trial before surgical intervention. Arthroscopic excision was generally reserved for persistent extension deficits and was associated with favorable outcomes and low recurrence rates. However, substantial variability persisted regarding the role of remnant preservation, timing of surgery, and indications for imaging, highlighting unresolved clinical controversies. CONCLUSIONS:While substantial variability exists in the management of cyclops syndrome after ACLR, consistent clinical patterns can be identified. Based on these findings, a stepwise management approach can be proposed, emphasizing early recognition of extension deficit, selective use of imaging, and a staged treatment strategy. These results provide a foundation for future efforts toward consensus guidelines and standardized care pathways. LEVEL OF EVIDENCE:Level V, cross-sectional survey study.

Abstract Purpose Evaluating knee joint function, activity level, and osteoarthritis severity in patients at least 8 years after post‐operative knee septic arthritis (SA) following anterior cruciate ligament reconstruction (ACLR). Methods From May 2010 to January 2012, 39 patients at our institution were treated for knee SA following ACLR using graft‐retaining treatment protocols. Follow‐up examinations after a minimum of 8 years included clinical examination, measurement of anterior tibial translation (rolimeter), International Knee Documentation Committee Subjective Knee Form (IKDC), 12‐Item Short Form Health Survey (SF‐12), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx and Tegner scores. Osteoarthritis severity was described on radiographs using the Kellgren–Lawrence scale. Synovial fluid was aspirated from patients with persistent infection signs and evaluated using multiplex polymerase chain reaction (PCR). Based on ACLR graft, sex and preoperative Tegner score (±1), a 1:1 propensity score matched control group including patients with ACLR without knee SA signs was assembled. Results Matching resulted in 17 patients per group. While the patient‐reported outcome measures (PROMs) (IKDC, Tegner, Marx and SF‐12) showed no significant differences between the groups (p > 0.05), the WOMAC score was significantly worse in the infection group (p = 0.016). Range of motion deficits were more frequent in the infection group (65% vs. 18%; p = 0.005). The infection group also had higher Kellgren–Lawrence grades (2 [1–2.75] vs. 0 [0–1], p < 0.001). Multiplex PCR detected no persistent infection. Two patients (10%) in the infection group required graft removal. No correlation was found between the number of lavages and long‐term outcomes. Conclusions SA after ACLR, when treated with a standardized graft‐retaining protocol, results in higher OA severity, worse WOMAC scores and persistent range of motion limitations at long‐term follow‐up, while other PROMs and activity level remained comparable to those of non‐infected cases. Level of Evidence Level III.

Purpose:The aim of this consensus was to provide evidence-based recommendations for individual rehabilitation interventions following anterior cruciate ligament reconstruction. These recommendations are intended to complement, rather than replace, comprehensive criterion-based rehabilitation protocols. Methods:A modified Delphi process conducted by the German Knee Society evaluated 29 rehabilitation topics. Evidence from systematic reviews, randomized controlled trials and prospective cohort studies (A1-C) was summarized and rated by an expert panel. Consensus was defined as ≥80% agreement between raters. Statements were graded using the Grading of Recommendations Assessment, Development and Evaluation framework, specifying the certainty of evidence. Results:Consensus was achieved for 25 topics (86%). Moderate-certainty evidence (B2) indicates that early weight bearing likely results in safe functional recovery. Supervised and unsupervised exercise (A2-B2) likely results in improved strength and function. Rehabilitation lasting ≥9 months (A1) likely results in optimal recovery guided by functional progress. Neuromuscular training (A1) and proprioceptive training (B2) likely improve sensorimotor control and functional outcomes. Plyometric (B2) and eccentric exercises (B2), as well as blood flow restriction (A1), likely result in enhanced quadriceps strength and muscle mass. Core stability exercises (C) and aquatic therapy (B1) likely improve knee function and facilitate early return to activity. Adjunctive modalities, such as cryotherapy (A2), likely reduce pain and swelling; KT (C) and digital applications (B1) may improve early-phase outcomes. Interventions such as whole-body vibration training (B2) and cross-education (C) showed inconsistent or insufficient benefits. Rehabilitation should be individualized according to patient-specific factors, concomitant injuries and functional progress. Conclusion:These consensus recommendations provide a multimodal, evidence-based framework for anterior cruciate ligament rehabilitation. Following these recommendations likely reduces variability in clinical practice, supports safe return to sport and might lower the risk of re-injury. Level of Evidence:Level V, expert consensus.

AIM:Anterior cruciate ligament reconstruction (ACLR) in patients over 50 years has traditionally been considered controversial due to concerns about graft failure, limited healing potential, and the risk of degenerative progression. However, with increasing life expectancy and higher physical activity in older adults, the demand for ACLR in this population has grown, and the role of graft selection remains unclear. The aim of this study was to evaluate the influence of graft choice on clinical outcomes, graft survival, and re-rupture rates after ACLR in patients aged 50 years and older. It was hypothesized that (1) ACLR in this population would result in low re-rupture rates and satisfactory functional outcomes, and (2) no significant differences would be observed among different graft types. EVIDENCE REVIEW:A systematic literature search of PubMed, Embase, and the Cochrane Library was performed from database inception to July 20, 2025, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included skeletally mature patients ≥50 years undergoing primary ACLR with different grafts (hamstring tendon [HT], bone-patellar tendon-bone [BPTB], quadriceps tendon [QT], allograft, or synthetic). Outcomes of interest included graft re-rupture, Lysholm score, and International Knee Documentation Committee (IKDC) subjective score. Random-effects meta-analyses were conducted to pool results, and subgroup analyses were performed by graft type. FINDINGS:Twenty-one studies including a total of 1093 patients were analyzed. The overall weighted mean age at surgery was 55.88 years (95% confidence interval [CI], 54.6-57.2). The majority of patients underwent HT reconstruction (n = 744-68.1%), followed by QT (n = 142-12.9%), BPTB (n = 81-7.4%), allograft (n = 110-10.1%), and synthetic grafts (ligament augmentation and reconstruction system [LARS]; n = 16-1.5%). The overall re-rupture rate was 0.3% (95% CI, 0.0-1.4), with no statistically significant differences among graft types (p > 0.05), ranging from 0.0% for BPTB/QT to 1.8% for allograft/LARS. The pooled mean Lysholm score was 91.2 (95% CI, 89.5-92.9), and the pooled mean IKDC score was 81.4 (95% CI, 77.9-84.9), showing no statistically significant graft-related differences. Odds ratio analysis confirmed no increased risk of re-rupture across graft types. CONCLUSIONS:ACL reconstruction in patients aged 50 years and older is associated with excellent functional outcomes and very low re-rupture rates. No statistically significant differences were observed among graft types. These findings should be interpreted with caution due to limited data for some graft categories and the heterogeneity of the available evidence. Graft selection should be individualized based on patient characteristics and surgeon expertise rather than chronological age. STUDY DESIGN:Systematic review and meta-analysis; level of evidence, III.

INTRODUCTION:The aim of this study was to establish a consensus-based classification of postoperative events following anterior cruciate ligament reconstruction (ACLR), clearly distinguishing no complication/normal clinical course, minor complication, major complication, and failure, using a structured Delphi methodology among international experts in anterior cruciate ligament (ACL) surgery. METHODS:A three-round modified Delphi process was conducted involving international high-volume ACL surgeons. An initial set of statements addressing potential postoperative events after ACLR was developed by a working group based on clinical expertise and contemporary literature. Panelists classified each statement as no complication/normal clinical course, minor complication, major complication, or failure. Consensus was predefined as ≥75% agreement within a single category. Statements reaching consensus were retained, whereas non-consensus statements were revised and re-evaluated in subsequent rounds. RESULTS:Thirty-nine experts completed the first and second Delphi rounds, and 30 (76.9%) completed the third round. The initial 52 statements were expanded to 67 in round two and refined to 46 in round three. Consensus was achieved for 14 statements (26.9%) in round one, 21 statements (31.3%) in round two, and 20 statements (43.5%) in round three. Overall, consensus was reached for 55 statements, forming the final classification framework. The panel clearly distinguished graft failure-defined as graft insufficiency or symptomatic instability-from major complications requiring surgical intervention or associated with substantial morbidity, and from minor complications or expected postoperative findings. Notably, traumatic graft rupture following a clearly documented new injury was not considered a postoperative complication. CONCLUSIONS:This international Delphi consensus establishes a standardized and clinically meaningful classification of postoperative events following ACLR. By clearly distinguishing no complication, minor complication, major complication, and failure, this framework provides a shared language that may improve consistency in outcome reporting, facilitate comparison across studies, and enhance the interpretability of clinical research and registry data. LEVEL OF EVIDENCE:V, expert consensus.

In cruciate ligament injuries in childhood and adolescence, bony avulsion injuries are common in addition to purely ligamentous ruptures. The injury patterns and mechanisms, continued longitudinal growth and psychosocial factors must be taken into account in the diagnostics and treatment. This article describes the most important techniques of surgical and nonoperative management, the associated rehabilitation protocols, as well as options for primary and secondary prevention.

BACKGROUND AND OBJECTIVE:Cefazolin is widely used for perioperative antibiotic prophylaxis and exhibits high protein binding. As only the unbound fraction exerts antimicrobial activity, understanding protein binding at the target site is essential. This study aimed to characterize the protein binding pattern of cefazolin in human knee and shoulder synovial fluid. METHODS:This prospective study included adult patients undergoing arthroscopic or open knee or shoulder surgery who received 2 g of intravenous cefazolin as part of routine perioperative antibiotic prophylaxis. Synovial fluid was aspirated immediately before arthroscope insertion or after joint capsule exposure. Total and unbound cefazolin were quantified using an ultra-high-performance liquid chromatography system coupled to mass spectrometry. Protein binding was calculated from paired total and unbound measurements. Concentration dependence was assessed by examining the relationship between the unbound fraction and the unbound concentration, with protein binding saturation defined by the presence of a plateau in this relationship. Statistical significance was defined as p < .05. RESULTS:A total of 201 patients were included. Median total and unbound cefazolin concentrations in synovial fluid were 40.4 mg/L and 13.7 mg/L, respectively, corresponding to a median unbound fraction of 24.6%. The unbound fraction increased with rising unbound concentration (r = 0.38; p < .001) without evidence of plateau formation within the observed range. CONCLUSIONS:Cefazolin exhibits concentration-dependent, but not saturated, protein binding in human synovial fluid after single-dose perioperative antibiotic prophylaxis.

Purpose: Cyclops syndrome remains a clinically relevant cause of extension deficit after anterior cruciate ligament reconstruction (ACLR), yet its prevention, diagnosis, and management are not standardized. The purpose of this study was to characterize practice patterns, identify areas of consensus and controversy, and derive a clinically applicable management framework based on an international survey of knee surgeons. Methods: A 69-item online survey was distributed to orthopedic surgeons specialized in knee surgery through multiple international societies. The questionnaire explored five domains: surgeon characteristics, surgical techniques, preventive strategies, diagnostic approaches, and management of cyclops syndrome. Descriptive statistics were used to summarize responses. Results: A total of 250 surgeons from 25 countries completed the survey. Most respondents estimated the incidence of cyclops syndrome between 1% and 5%, with symptomatic presentation typically occurring within 3–6 months after ACLR. Loss of extension greater than 5° was consistently identified as the key clinical finding. Magnetic resonance imaging was the preferred first-line diagnostic modality.Despite heterogeneity in several aspects of care, consistent patterns emerged. Accurate tibial tunnel positioning and restoration of full preoperative knee extension were considered the most critical preventive factors. Initial management was predominantly conservative, with most surgeons advocating an extension-focused rehabilitation trial before surgical intervention. Arthroscopic excision was generally reserved for persistent extension deficits and was associated with favorable outcomes and low recurrence rates.However, substantial variability persisted regarding the role of remnant preservation, timing of surgery, and indications for imaging, highlighting unresolved clinical controversies. Conclusions: While substantial variability exists in the management of cyclops syndrome after ACLR, consistent clinical patterns can be identified. Based on these findings, a stepwise management approach can be proposed, emphasizing early recognition of extension deficit, selective use of imaging, and a staged treatment strategy. These results provide a foundation for future efforts toward consensus guidelines and standardized care pathways. Level of Evidence: Level V, cross-sectional survey study.

PURPOSE:Finding prognostic factors for a subsequent injury after an anterior cruciate ligament (ACL) reconstruction. METHODS:We re-analysed the data of two intervention studies on adults with a hamstrings or quadriceps tendon ACL reconstruction. All participants were prospectively monitored for 24 months. At the end of the individual postsurgery rehabilitation, numerous self-reported and objective functional outcomes were quantified, all potential secondary injuries (primary outcome was the occurrence of secondary ipsi- or contralateral ACL injuries) and all rehabilitation and training measures were prospectively monitored. The association of potential factors with a secondary injury risk was determined using logistic mixed models. RESULTS:We included 148 participants (mean age 25.3 years [standard deviation 5.1 years], 63 females). Eight participants had a subsequent ACL injury, among them seven ispilateral and one contralateral side ACL rupture. The final model for the likelihood of a subsequent ACL injury led to a sensitivity (correctly classified participants who had a subsequent ACL injury) of 83.3% and to a specificity (correctly identified participants without who did not have a subsequent ACL injury) of 100% (n = 93). The main contributing factors to subsequent ACL or any subsequent other injuries were: higher kinesiophobia values (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.1-3.4), higher knee loading levels during activity (Tegner activity scale, OR = 29, 95% CI: 1.1-791), lower performance levels at the Balance front hop (OR = 0.13, 95% CI: 0.03-0.52), and higher dynamic valgus (knee separation distance in the frontal plane) during the landing of a drop jump landing (OR = 0.80, 95% CI: 0.65-0.98). CONCLUSION:Most of the predictive factors for a second subsequent injury after an ACL reconstruction are modifiable by adequate training and rehabilitation measures. The modification of these factors might decrease the secondary risk of injury risk. LEVEL OF EVIDENCE:Level II, a prospective cohort study.

PURPOSE:To define expert consensus on whether and how lateral extra-articular procedures (LEAPs) should accompany anterior cruciate ligament (ACL) reconstruction to optimize outcomes in ACL-deficient knees. METHODS:Fifty-five knee surgeons from 17 countries on 5 continents completed a 3-round modified Delphi process. Twenty-one statements on patient selection for combined ACL reconstruction (ACLR) + LEAPs were graded on 5-point Likert scales; ≥75% "agree/strongly agree" signified consensus. Strength of recommendation was ranked, and statements failing the threshold were revised or discarded after discussion. RESULTS:One statement achieved unanimous agreement (100%): it is strongly recommended to add a LEAP for active patients ≤25 years receiving hamstring-autograft ACLR to reduce graft failure. Strong consensus (≥90%) supported LEAPs in primary ACLR when grade 3 pivot shift (97.9%), knee hyperextension (97.9%), skeletally immature status (79.5%), revision ACLR (91.5%), return to pivoting sports (93.2%), active patients ≤25 years using nonhamstring grafts (90.7%), grade 3 Lachman test (90%), and when multiple relative risk factors coexist (statement 36, 97.1%). Consensus (75%-89.9%) favored LEAPs for chronic symptomatic ACL deficiency (86.1%), posterior tibial slope >12° (85.7%), and a history of contralateral ACL injury (88.9%). Eight statements did not reach consensus regarding small-diameter autografts, female athletes, imaging signs of anterolateral injury (e.g., Segond fracture, lateral femoral-notch sign), and concomitant meniscal procedures. One statement on LEAPs with primary ACL repair was withdrawn because the project focused on reconstruction. CONCLUSIONS:International experts strongly recommend adding a LEAP in young active patients undergoing hamstring-autograft ACLR and in cases of high-grade rotational or anterior laxity, knee hyperextension, revision surgery, or returning to pivoting sports. Unresolved issues include small graft size, female athletes, imaging findings of rotational instability, and concurrent meniscal procedures, highlighting priorities for future research. LEVEL OF EVIDENCE:Level V, expert opinion.

Late-stage rehabilitation interventions after an anterior cruciate ligament (ACL) reconstruction are under-researched, inter alia regarding potential differences in rehabilitation effects between autograft types. This study determined the effectiveness of a specific, late-stage rehabilitation to usual care after ACL reconstructions in patients with a quadriceps versus such with a hamstring tendon autograft. In this multicentre case-control intervention study, participants aged 18-35 years were included at the end of their formal rehabilitation (mean 8.1 months) after ACL reconstruction. Twenty-four cases with an arthroscopically assisted, anatomic ipsilateral quadriceps femoris tendon autograft and two numerically equal hamstring tendon reconstructed propensity score-matched groups were compared. Matching variables were gender, age, Tegner activity scale, plus, once, the time since reconstruction and once the functional capacity at intervention onset. All participants performed a 5-month performance enhancing intervention. All outcomes were measured once a month. Self-reported outcomes such as knee function (The Knee injury and Osteoarthritis Outcome Score (KOOS) Sport as the main self-reported outcome) were followed by a series of hop and jump tests. The front hops for distance (outcome: hopping distance) was the primary outcomes of the study. Linear mixed models were calculated using change scores. All participants were analysed. No group*time interaction effect could be identified in the two main outcomes KOOS SPORT and front hop for distance. Furthermore, with the exception of the self-reported all-day function, no outcome displayed any between-group differences in the trainability, either. The return-to-sport success took a mean time of 3.8 months after study commencement; the success rates ranged between 80% and 83% and were not different between groups. Being reconstructed with a hamstrings or with a quadriceps tendon autograft had no impact on the late-stage rehabilitation effects after an ACL rupture. Both graft choices enable comparably favourable functional outcomes and return-to-sport success rates. Conversely, no recommendation can be derived with regard to the selection of either a hamstring or a quadriceps autograft type. The decision must be undertaken individually and based on other factors.

OBJECTIVES:To find contributors to return to sport success or time until return to sport in individuals after an anterior cruciate ligament reconstruction. DESIGN:Cohort study. METHODS:Secondary analysis of the data of two intervention studies. PARTICIPANTS:We included adults < 36 years of age with a tendon autograft anterior cruciate ligament reconstruction who were active in any type of sport prior to the injury and aiming to return to sport. All participants were prospectively monitored for 24 months. INTERVENTIONS:At the end of the individual post-surgery rehabilitation and re-injury prevention programmes, self-report- and objective functional outcomes were quantified. MAIN OUTCOME MEASURES:The potential return to sport success (return to the same type of sports, frequency, intensity, and quality of performance as pre-injury), secondary injuries, and all rehabilitation and training measures were prospectively monitored. To determine the contributing factors, Cox regressions for traits and baseline factors and a logistic mixed model, which also included prospective time-dependent factors, were calculated. RESULTS:203 participants were included; 104 (51 % of the total sample and 68 % of the full cases) successfully returned to their sporting activity. The median duration until return to sport was 302 days (interquartile range was 114 days). Contributing factors were the type of working (blue- vs. white collar: odds ratio for return to sport = 0.51 [95 % confidence interval = 0.29 to 0.90]) and the athletic status (elite vs. non-elite: odds ratio = 2.28 [1.03 to 5.03]). Prospectively, higher rehabilitation volumes until the end of the rehabilitation were predictive for return to sport success: the odds ratio per additional hour of rehabilitation was 1.004 [1.001 to 1.006]. Functional abilities such as the normalised knee separation distance during drop jump landing (odds ratio = 0.961 [0.924 to 0.999]) were predictive at a later stage, at the end of the re-injury prevention. Psychological readiness for return to sport was predictive at most of the timepoints: those who were confident to return to sport were more successful to return to sport at the end of the rehabilitation (odds ratio = 1.029 [1.004 to 1.056]) and at the end of the re-injury prevention (odds ratio = 1.038 [1.004 to 1.073]). CONCLUSIONS:The most important factors for a successful pre-injury-level return to sport after anterior cruciate ligament reconstruction were the exercise volume, psychological readiness and functional hop/jump abilities. Whilst the impact of these modifiable factors was robust against multilevel modelling, the impact of athletic and working status vanishes when the prospective factors are included.

Purpose:The purpose of the study was to determine the prevalence of proximal tibiofibular joint (PTFJ) dislocations in knee dislocations classified as Schenck type ≥III and to compare with uninjured contralateral knees, which served as control cohort. Methods:Patients treated at Cologne Merheim Medical Center with knee dislocation ≥III between 2015 and 2022 were included, while one control group consisted of uninjured contralateral knees. In addition to established PTFJ-specific parameters, two novel computed tomography-based PTFJ parameters were implemented on scans obtained a mean of 5 days post-trauma. The fibula lateralisation quantifies the lateral shift of the proximal fibula joint line in relation to the tibial PTFJ joint line. The posterior fibula area quantifies the fibula position in the sagittal plane with reference to the posterior tibial margin. Results:A total of 107 knee joints were included, comprising 40 with knee dislocation ≥III, 24 uninjured contralateral knees and 43 chronically isolated anterior cruciate ligament insufficient knees. The overall cohort had a median posterior fibula area of 92.7% and a fibula lateralisation of 0.0%. Complete PTFJ dislocation was observed in 5.4% of knee dislocation cases, all in type IV injuries. Fibula lateralisation analysis indicated PTFJ subluxation in an additional 21.6% of cases. No PTFJ dislocations were present in the contralateral knee group. The knee dislocation group differed significantly from the matched contralateral knee group with regard to fibula lateralisation (r = 0.43; p = 0.007), whereas no differences were observed for inclination-horizontal (p = 0.620), inclination-fibular axis (p = 0.082) and obliquity (p = 0.602). Conclusions:This study demonstrates a 5.4% prevalence of PTFJ dislocation in knee dislocations ≥III, which is lower than previously reported. The incidence of PTFJ dislocation in knee dislocations type IV is high at 33.3%. Fibula lateralisation and posterior fibula area are suitable parameters for assessing anterolateral dislocation of the proximal fibula. Inclination-horizontal, inclination-fibular axis and obliquity show no relevant side-to-side differences in individuals. Level of Evidence:Level III.

Objective: To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction. Methods: In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not. Results: At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers." Conclusions: The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.

PurposeThe aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient.MethodsFor 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.ResultsDuring 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.ConclusionsThis 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 EvidenceLevel V. For the first time, a consensus project was able to provide recommendations that could help standardise the surgical procedure in the treatment of ACL injuries. image

Abstract Purpose To clarify whether different methods of quantifying lateral femoral condyle (LFC) bone morphology as risk factors for anterior cruciate ligament (ACL) injury on lateral radiographs should be considered as individual risk factors and to assess inter‐ and intraobserver reliability. Methods We retrospectively reviewed 487 patients undergoing primary ACL reconstruction at our institution. Routine lateral radiographs of the injured knees were utilized to measure the following parameters: LFC ratio (LFCR), height of LFC to anteroposterior diameter ratio (HAPR), femur tibia size ratio (FTSR), tibia to posterior femoral condyle ratio (TPFCR) and Porto ratios (XY/AB; B/AB; B/XY). Malrotated radiographs were excluded. Pearson's correlation coefficients were used to identify relationships. Intraclass correlation coefficients were calculated for inter‐ and intraobserver reliability for two raters. Results Fifty‐eight patients were included. Means and standard deviations for LFCR were 63.7% ± 2.8%, HAPR 0.35 ± 0.02, FTSR 1.23 ± 0.07, TPFCR 2.99 ± 0.28, XY/AB 0.41 ± 0.08, B/AB 1.20 ± 0.06 and B/XY 3.05 ± 0.58. Significant correlations were observed between FTSR and XY/AB (r = 0.425), B/AB (r = 0.582) and TPFCR (r = −0.326), between XY/AB and HAPR (r = −0.309) and B/XY (r = −0.933) and between TPFCR and B/AB (r = 0.302). Intraobserver agreement was excellent for LFCR, HAPR, FTSR, TPFCR and B/AB and good for XY/AB and B/XY. Interobserver agreement varied from poor for XY/AB and B/XY, good for HAPR, B/AB, FTSR and TPFCR to excellent for LFCR. Conclusion Different methods of quantifying LFC bone morphology should be considered as individual risk factors, characterized by good to excellent intraobserver reliability, but highly variable interobserver reliability. Level of Evidence Level III.

BackgroundAt the completion of formal rehabilitation after anterior cruciate ligament reconstruction, functional capacity is only restored in a small proportion of affected individuals. Therefore, the end of formal rehabilitation is not the end of functional rehabilitation.ObjectiveTo compare adherence to and effectiveness of a late-stage rehabilitation programme with usual care after anterior cruciate ligament (ACL) reconstruction.MethodsThis prospective, double-blind, multicentre, parallel group, randomised controlled trial, included people aged 18 to 35 years after formal rehabilitation completion (mean [SD] 241 [92] days post-reconstruction). Participants were block-randomised to a 5-month neuromuscular performance intervention (Stop-X group) or usual care (medically prescribed standard physiotherapy, individual formal rehabilitation, home-exercises). All outcomes were measured once/month. Primary outcome was the normalised knee separation distance on landing after drop jump. Baseline-adjusted linear mixed models were calculated.ResultsIn total, 112 participants (Stop-X: 57; Usual care: 55,) were analysed. Initially, mean (SD) intervention frequency (units/week) was higher in the Stop-X than the Usual care group: 2.65 (0.96) versus 2.48 (1.14) units/week in the first and 2.28 (1.02) versus 2.14 (1.31) units/week in the second month. No between-group*time(*baseline)-differences were found for the primary outcome. Between-group*time-effects favoured the Stop-X-group at 2 months (fewer self-reported knee problems during sport, KOOS-SPORT) (estimate = 64.3, 95 % CI 24.4–104.3 for the Stop-X), more confidence to return to sport (ACL-RSI) (62.4, 10.7–114.2), fewer pain-associated knee problems (KOOS-PAIN) (82.8, 36.0–129.6), improved everyday activity abilities (KOOS-ADL) (71.1, 6.4–135.7), and improved limb symmetry index in the front hop for distance at 3 and 4 months (0.34, 0.10–0.57; 0.31, 0.08–0.54). No between-group*time-effects occurred for kinesiophobia, symptom-associated knee problems or balance hops performance. At the end of the intervention, 79 % of the Stop-X and 70 % of the Usual care participants (p < 0.05) had successfully returned to their pre-injury sport type and level.ConclusionsThe Stop-X intervention was slightly superior to usual care as part of late-stage rehabilitation after ACL-reconstruction. The small benefit might justify its use after formal rehabilitation completion.

A knee dislocation is a serious injury involving at least two of the four major ligamentous stabilizers of the knee. This injury results in multidirectional knee instability. In dislocation of the knee the popliteal artery and the peroneal nerve can also be damaged. Dislocations with vascular involvement are potentially threatening injuries of the lower extremities. The diagnosis of knee dislocation can be difficult due to a high rate of spontaneous reduction at the initial examination. Knee dislocations are rare and mainly occur in young men. They are mostly caused by high-energy trauma; however, they can also be caused by low-energy injuries. Obesity increases the risk of knee dislocations. The classification of a knee dislocation is based on the anatomical structures involved and the direction of dislocation. The acute treatment includes reduction and stabilization measures. Associated injuries, such as vascular, nerve, extensor mechanism and cartilage injuries as well as fractures and meniscal injuries can influence the treatment approach and the outcome. The definitive surgical treatment depends on the severity of the injury and can include ligament reconstruction or repair with bracing. The aftercare should be individually adapted with the aim to restore knee joint stability and function. Complications such as arthrofibrosis, peroneal nerve palsy, compartment syndrome, postoperative infection and recurrent instability can occur. In the long term, patients have an increased risk for the development of symptomatic osteoarthritis.