Statistische Fragilität beschreibt, wie stabil oder instabil die Ergebnisse klinischer Studien gegenüber kleinen Änderungen einzelner Datenpunkte sind. Gerade in der Arthroskopie und Gelenkchirurgie, in der viele Studien auf kleinen Stichproben und seltenen Ereignissen basieren, kann bereits der Wechsel weniger Patient:innenergebnisse dazu führen, dass statistische Signifikanz verloren geht. Der Fragility-Index sowie seine Weiterentwicklungen für kontinuierliche und nichtsignifikante Endpunkte erlauben eine intuitive Einschätzung dieser Robustheit und ergänzen klassische Kennzahlen wie p-Wert und Konfidenzintervalle. In diesem Übersichtsartikel werden die Konzepte der statistischen Fragilität, ihre Berechnung für binäre und kontinuierliche Variablen sowie ihre Bedeutung für die Interpretation gelenkchirurgischer Studien dargestellt.

Avulsionsfrakturen des Kniegelenks betreffen am häufigsten die Insertionsstellen des vorderen (VKB) und hinteren Kreuzbands (HKB), des anterolateralen Komplexes (Segond-Fraktur), des posterolateralen Bandkomplexes (PLC), als Arcuate-Sign, des medialen Bandkomplexes (Reverse-Segond-Fraktur, Stieda-Fraktur) sowie des Streckapparats (Patella-Sleeve-Frakturen). Besonders häufig sind dabei tibiale Eminentiafrakturen (VKB-Avulsionen) bei Kindern und Jugendlichen sowie tibiale Avulsionen des HKB bei Hochenergietraumata. Die Diagnostik erfolgt primär mittels konventioneller Röntgenaufnahme zur initialen Detektion knöcherner Ausrisse. Avulsionsfrakturen besitzen häufig eine hohe diagnostische Bedeutung als indirekte Hinweiszeichen auf zugrunde liegende Bandverletzungen. So gelten beispielsweise Segond-Frakturen als pathognomonisch für Rupturen des VKB. Zur genaueren Beurteilung von Fragmentgröße, Dislokation und intraartikulärer Beteiligung kommen die CT und insbesondere die MRT zum Einsatz, welche zusätzlich relevante Begleitverletzungen an Menisken, Knorpel und Bandstrukturen erfassen. Je nach Lokalisation und Ausmaß der Fragmentverschiebung kann die Therapie von Knie-Avulsionsfrakturen variieren und ist nicht immer eindeutig standardisiert. Die verfügbare Datenlage ist besonders bei seltenen Entitäten begrenzt. Nichtdislozierte oder nur minimal dislozierte Frakturen lassen sich in der Regel konservativ behandeln, typischerweise durch initiale Ruhigstellung mit anschließender strukturierter Rehabilitation. Demgegenüber erfordern dislozierte Frakturen, relevante Instabilitäten oder eine Beteiligung des Streckapparates meist eine operative Reposition und Fixation, um die Funktion und Gelenkstabilität wiederherzustellen.

PURPOSE:To investigate whether clinically failed anterior cruciate ligament (ACL) reconstructions can be accurately identified using magnetic resonance imaging (MRI). METHODS:This prospective case series included 81 patients (mean age 33.5 ± 11.9 years, 50.6% male) with clinically failed ACL reconstructions defined by Lachman ≥ Grade 2, Pivot-shift ≥ Grade 2 and/or anterior tibial translation side-to-side difference (ATT SSD) > 5 mm measured using a Rolimeter (Aircast®). MRI graft status was assessed using the anterior cruciate ligament Osteoarthritis Score (ACLOAS) and categorized into: Status 0/1 (regular/hyperintense), Status 2 (thinned/elongated) and Status 3 (ruptured). Secondary measures comprised MRI meniscus and cartilage status, alongside baseline clinical and functional assessments, including the International Knee Documentation Committee (IKDC), Lysholm and Tegner score. RESULTS:Graft status was classified as Status 3 (ruptured) in 51 (63.0%) cases, while 30 (37.0%) were intact (18 [22.2%] Status 0/1; 12 [14.8%] Status 2). Meniscus and cartilage were unremarkable in 30 (37.0%) and 31 (38.3%) cases, respectively, without significant correlation to graft status (p = 0.135 and p = 0.846). Mean ATT SSD was 6.6 ± 1.6 mm without significant group differences (p = 0.163). Lachman Grade 2+ predominated in Status 0/1 (14 [77.8%]), whereas Lachman Grade 3+ was more frequent in Status 2 (9 [75.0%]) and Status 3 (28 [54.9%]). Status 2 grafts showed a significant excess of Lachman Grade 3+ over Grade 2+ (p = 0.011). Grade 2 pivot-shift was found in majority of cases (highest in Status 0/1 with 12 [66.7%]), while Status 2 showed the highest proportion of Grade 3 instability (4 [44.4%]). Between-group differences were not statistically significant (p = 0.185). Tegner was significantly lower in Status 3 (p = 0.014), while IKDC (44.5 ± 15.9, p = 0.786) and Lysholm (52.2 ± 21.2, p = 0.547) showed no significant group differences. CONCLUSIONS:Clinical failure following ACL reconstruction correlates only in 63.0% of cases with MRI-based graft status. The findings indicate that clinical assessment should guide diagnosis, while MRI remains most valuable for identifying associated intra-articular lesions. LEVEL OF EVIDENCE:Level IV, prospective case series design.

Die rezidivierende vordere Schulterinstabilität führt häufig zu einem anterioren Knochenverlust des Glenoids. Diese mit der chronischen Instabilität einhergehende Glenoiderosion wird zunehmend mittels knöcherner Augmentation des anterioren Glenoids behandelt, um das Glenohumeralgelenk ausreichend zu stabilisieren. Zur Fixierung der knöchernen Grafts werden mittlerweile verschiedene Techniken eingesetzt. Traditionell wurden Schraubenfixationen verwendet. Um Komplikationen zu vermeiden, die mit der Verwendung von Schrauben verbunden sind, kommen zunehmend Faden-Knopf-Konstrukte („suture buttons“ oder „Button-Rekonstruktion“), Fadencerclagen und Fadenanker-Techniken zum Einsatz. Nach übereinstimmenden Erkenntnissen biomechanischer Untersuchungen ist bei der Schraubenfixation sowohl mit höherer Anzahl der Schrauben als auch der Verwendung von Unterlegscheiben die Steifigkeit der Konstruktion und die Versagenslast signifikant erhöht. Beim Vergleich von Button- mit Schraubenfixationen ergaben sich uneinheitliche Ergebnisse. Jedoch zeigt sich, dass alle Konstrukte mit zwei Metallschrauben sowie der Großteil der Konstrukte mit Buttons und Ankern einer glenohumeralen Belastung standhalten, die den Aktivitäten des täglichen Lebens entspricht. Klinische und radiologische Studien berichten über vergleichbare Ergebnisse sowohl bei schrauben- als auch bei fadenbasierten Fixationsmethoden, wobei Hinweise auf eine vermehrte Knochenresorption bei der Schraubenfixation bestehen. Obwohl die neuartigen Techniken mit einer gering erhöhten Rate an Rezidiv-Instabilität verbunden sind, sind die Gesamtraten an Reoperationen und Komplikationen geringer.

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: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.

Background Anterior and posterior cruciate ligament injuries have increased in recent years and predominantly affect young individuals, posing a growing challenge to the German insurance system. The aim of this study was to analyze the frequency of cruciate ligament injuries and to assess associated work incapacity, treatment costs, and pension payments. Methods This retrospective registry study analyzed anonymized data from the rehabilitation database (Reha-DOK) for accident years 2010 to 2020. Cases were identified using the injury site code for cruciate ligaments (code 811) and the injury type code for complete rupture (code 43). Only isolated complete cruciate ligament injuries without associated injuries were included. Annual case numbers, age distribution, time to return to work (RTW), documented long-term impairment in pension cases, reduction in earning capacity, treatment costs, and pension payments were analyzed. Results A total of 21,918 cruciate ligament injuries were included, and 65.5% of affected individuals were male, mean age was 32.3 ± 13.6 years. From 2010 to 2019, cruciate ligament injuries increased by 30.4% (p < 0.0001), whereas the overall cohort of inpatient accident injuries showed no significant change. Individuals aged 15 to 20 years were most frequently affected (19.0%). Data on RTW were available for 14,875 cases; mean time to RTW was 160 ± 133 days. RTW exceeded 3 months in 67.3% of cases and 1 year in 8.8%, whereas RTW within less than 2 weeks was observed in 7.3%. The most frequent long-term impairments were restriction of motion (50.5%), muscle atrophy (14.3%), and ligament laxity or insufficiency (13.8%). Pension payments due to reduced earning capacity were documented in 6.4% of cases. Average costs increased significantly from 2010 to 2019 by 21.1% (p < 0.0001). The lifetime total costs per affected insured individual was calculated to €209,483 ± €119,757. Conclusions Frequency of cruciate ligament injuries significantly increased over time and affected predominantly young individuals aged 15 to 20 years. The prolonged RTW and substantial lifetime costs indicate a considerable socioeconomic burden for the German Statutory Accident Insurance system.

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 orthopedics and sports medicine, understanding biomechanics is essential for optimizing performance and preventing injuries. Traditional motion-capture methods are often impractical in dynamic, real-world sports settings. Recent advances in artificial intelligence (AI)-powered video analysis, especially markerless motion tracking, offer promising solutions to these challenges. However, applying these technologies in unconstrained environments like live sports remains complex. This article aims to review state-of-the-art computer vision methods used in sports medicine, focusing on the challenges and solutions of AI-based video analysis in real-world settings. It evaluates the effectiveness of monocular and multi-view systems in analyzing athlete motion and biomechanics during live competition. We review the latest video-based 3D human motion analysis techniques from the past 5 years, focusing on challenges such as occlusion, camera calibration, and multi-person tracking in sports environments. We highlight open-sourced algorithms and their applications, including monocular and multi-view approaches for biomechanical assessments. Artificial intelligence-based video analysis has shown significant progress, with monocular models achieving reliable results in controlled environments and multi-view systems, improving tracking accuracy in dynamic settings. Despite these advancements, issues like occlusion, synchronization, and limited real-world data still hinder broad application. Data variability and the need for personalized models remain significant challenges. While monocular systems excel in controlled environments, multi-view setups are essential for accurate analysis in team sports. Future developments must balance model accuracy with practical implementation in diverse sports contexts. Collaboration between clinicians, engineers, and industry stakeholders will be crucial for advancing AI-powered video analysis in sports medicine.

The antegrade planning method according to Miniaci was primarily developed for high tibial osteotomies but is also used by several surgeons for planning of distal femoral osteotomies (DFO) in daily clinical practice. Strecker adapted in 2006 the Miniaci method as a retrograde method for planning of DFO. It is not yet known whether there is a difference between the planning methods for correction angles and osteotomy wedge heights in DFO planning. Three knee surgeons independently performed DFO planning with the antegrade Miniaci method, the retrograde method and the semiautomated method with the software mediCAD® as a gold standard on 40 anonymized preoperative whole-leg X-rays of patients with a coronal deformity treated with DFO. Subsequently, the difference for correction angles and osteotomy wedge heights between the three methods was analyzed and the interobserver reliability was calculated. The retrograde method resulted in significantly higher correction angles (+ 1.42° ± 0.55°; p < 0.001) and osteotomy wedge heights (+ 1,36 ± 0.61 mm; p < 0.001) than the antegrade Miniaci methods. A linear regression analysis showed a significant relationship between the extent of coronal deformity and the difference in correction angles between the two methods (p < 0.001, R2 = 0.74). The correction angles determined with the software-based method almost matched the values of the retrograde Miniaci method (mean difference: -0.06° ± 0.37°; p = 0.307). The interobserver reliability was almost perfect for all three techniques (ICC: antegrade: 0.85, retrograde: 0.92, software-based: 0.98). Planning a DFO with the antegrade Miniaci method results in lower correction angles and osteotomy wedge heights than with the retrograde method, which in turn exhibits comparable values to software-based method as gold standard, leading to the risk of undercorrection with the antegrade method. In order to reduce the risk of undercorrection in DFO, the retrograde method appears to be superior. Level 3 - diagnostic retrospective cohort study.

Systematische Übersichtsarbeiten und Metaanalysen spielen eine wichtige Rolle in der evidenzbasierten Medizin, indem sie wissenschaftliche Erkenntnisse systematisch erfassen, bewerten und zusammenfassen. Ihre Aussagekraft hängt jedoch maßgeblich von der methodischen Strenge sowie der Qualität der eingeschlossenen Studien ab. Dieser Artikel bietet eine Einführung in die Methodik systematischer Übersichtsarbeiten sowie in die kritische Betrachtung ihrer methodischen Ansätze.

Introduction: Postoperative neuralgias are common complications following orthopedic surgeries, particularly after knee ligament surgeries. This case report presents the treatment of postoperative saphenous nerve neuralgia with Onabotulinumtoxin A in a 45-year-old patient after a complex knee joint surgery. Case Description: The patient suffered a complex injury to the right knee joint, including a tear of the anterior cruciate ligament and the medial collateral ligament, as well as avulsion of the anteromedial joint capsule. In the postoperative course after cruciate ligament replacement with quadriceps tendon and open medial ligament reconstruction with gracilis tendon, the patient developed severe neuropathic pain (allodynia, burning sensations) at the medial ligament scar. Initially, treatment involved local anesthetics, pregabalin, and tramadol. With no therapeutic success, a subcutaneous injection of 30 units of Onabotulinumtoxin A (Xeomin) was administered three weeks postoperatively, resulting in rapid improvement of symptoms and near-complete resolution, particularly of the allodynia. After about six months, there was a resurgence of pain, especially the allodynia. A repeat injection treatment with 30 units of Onabotulinumtoxin A again led to significant improvement in symptoms as described above. Conclusion: The application of Onabotulinumtoxin Type A may serve as an effective therapeutic option for treating postoperative neuropathic pain, especially in cases that do not respond to conventional pharmacological and physical therapies. Further research is needed to verify the reproducibility of treatment success and to determine optimal dosages and potential injection intervals.

CASE:A 13-year-old adolescent boy and a 12-year-old girl, with torn anterior cruciate ligament (ACL) and increased posterior tibial slopes (PTS) of 17° and 19°, underwent transphyseal anterior tibial hemiepiphysiodesis and ACL reconstruction using a quadriceps autograft. Epiphysiodesis plates were removed after epiphyseal closure in the girl and after 12 months in the boy. Follow-up at 12 and 15 months showed Tegner and Lysholm scores of 4 and 100, with PTS reduced to 8° and 9°. Both resumed sports without further instability. CONCLUSION:Anterior tibial hemiepiphysiodesis effectively reduced the increased PTS to physiological levels in both cases.

Diese Arbeit vergleicht die klinischen Ergebnisse konservativer und operativer Behandlungen bei Rupturen des hinteren Kreuzbands (HKB). Ziel ist es, beide Therapieansätze hinsichtlich Kniestabilität, subjektiven Scores (Patient-Reported Outcome Measures, PROMs) und Rückkehr zum Sport (Return-to-Sport, RTS) zu beurteilen. Operative Verfahren zeigen bessere objektive Stabilitätswerte (z. B. geringere Restinstabilität, niedrigere Arthroseraten), während funktionelle Ergebnisse beider Methoden vergleichbar gut ausfallen. Konservative Therapien führen bei isolierten HKB-Verletzungen meist zu guten bis sehr guten PROMs (z. B. Lysholm‑, IKDC-, Tegner-Scores). Auch Operationen verbessern die PROMs, wobei die Ergebnisse stark von Verletzungsschwere, Begleitverletzungen und Rehabilitationsprotokollen abhängen. Nach konservativer Therapie erreicht eine hohe Anzahl an Sportlern das frühere Leistungsniveau, insbesondere bei isolierten, geringgradigen Verletzungen. Operative Eingriffe führen tendenziell zu niedrigeren RTS-Raten und längeren Rehabilitationsphasen. Konservative Verfahren sind bei isolierten, niedriggradigen HKB-Rupturen oft effektiv, während operative Rekonstruktionen bei hochgradigen oder kombinierten Verletzungen notwendig sein können. Die Wahl der Therapie muss individuell erfolgen. Es besteht weiterhin Bedarf an qualitativ hochwertigen Studien zur besseren Vergleichbarkeit.

Background:Less experienced surgeons have an increased risk for tunnel malpositioning as a predominant risk factor for failure of anterior cruciate ligament reconstruction (ACLR). Fluoroscopic guidance can improve the precision of tunnel positioning. Purpose:To investigate whether low-volume surgeons can achieve precise femoral tunnel placement in ACLR under fluoroscopic control comparable to that of experienced mid- and high-volume surgeons. Study Design:Cohort study; Level of evidence, 3. Methods:This study retrospectively included 150 patients who underwent primary ACLR between January 2021 and March 2023 and were prospectively enrolled in an in-clinic registry. Three groups were defined: high-volume surgeon (1 surgeon with >100 ACLRs per year; 50 images), mid-volume surgeon (1 surgeon with >10 to <50 ACLRs per year; 50 images), and low-volume surgeon (5 surgeons with ≤10 ACLRs per year; 50 images). The analysis of the femoral tunnel position was performed digitally on strictly lateral fluoroscopic images by determining the depth and height relations according to the quadrant method of Bernard and Hertel. Results:All surgeons, regardless of experience, achieved high precision of femoral tunnel placement (depth relation: SD, 3.41% [1.58 mm]; height relation: SD, 5.33% [1.33 mm]). The variances of the tunnel placements did not show significant differences between the 3 groups with the Brown-Forsythe test (depth relation: probability (Pr) > F = 0.332; height relation: Pr > F = 0.081; P < .05). The precision of the high-volume surgeon (depth relation: SD, 3.29%; height relation: SD, 4.92%) was comparable to that of the mid-volume surgeon (depth relation: SD, 2.98%; height relation: SD, 5.9%) and low-volume surgeon (depth relation: SD, 3.58%; height relation: SD, 4.62%). Conclusion:In this study, fluoroscopically guided tunnel placement allowed low-volume surgeons to achieve a level of precision comparable to that of the experienced surgeons. Fluoroscopy might especially help low-volume surgeons to achieve a standardized and highly reproducible femoral tunnel position and thus avoid tunnel malpositioning.

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.

Postoperative Neuralgien sind häufige Komplikationen nach orthopädischen Operationen, insbesondere nach Eingriffen am Kniegelenk. Dieser Fallbericht stellt die Behandlung eines 45-jährigen Patienten mit Onabotulinumtoxin A nach einer komplexen Kniegelenksoperation und postoperativer Nervus Saphenus-Neuralgie dar. Der Patient erlitt eine komplexe Verletzung des rechten Kniegelenkes, einschließlich Riss des vorderen Kreuzbandes und des Innenbandes sowie Avulsion der anteromedialen Gelenkkapsel. Im postoperativen Verlauf nach Kreuzbandersatz mit Quadrizepssehne und offenem Innenbandersatz mit Gracilissehne, entwickelte der Patient starke neuropathische Schmerzen (Allodynie, brennende Missempfindungen) an der Innenbandnarbe. Zunächst wurde mit Lokalanästhetika, Pregabalin und Tramadol behandelt. Bei ausbleibendem Therapieerfolg wurde 3 Wochen postoperativ eine subkutane Injektion mit 30 Einheiten Onabotulinumtoxin A (Xeomin) durchgeführt, was zu einer raschen Verbesserung der Symptome und nahezu vollständigem Rückgang insbesondere der Allodynie führte. Nach ca. 6 Monaten kam es wieder zu einer Schmerzverstärkung insbesondere der Allodynie. Eine erneute Injektionsbehandlung mit 30 Einheiten Onabotulinumtoxin A führte erneut zu oben beschriebener deutlicher Beschwerdebesserung. Die Anwendung von Onabotulinumtoxin Typ A könnte eine effektive Therapieoption zur Behandlung postoperativer neuropathischer Schmerzen sein, insbesondere in Fällen, die auf herkömmliche medikamentöse und physiotherapeutische Behandlungen nicht ansprechen. Weitere Forschung ist nötig, um die Reproduzierbarkeit des Therapieerfolges zu überprüfen und optimale Dosierungen und ggf. auch Injektionsintervalle zu bestimmen.

PURPOSE:To assess the effect of the knee flexion on the tibial tuberosity-trochlear groove (TT-TG) distance measurement by comparing conventional and whole-leg rotational magnetic resonance imaging (MRI). METHODS:This retrospective cohort study included 45 patients with patellar dislocations who had undergone both conventional knee MRI with the knee in slight knee flexion (20°-30°) and full-length rotational MRI in extension (0°-5°). TT-TG distances were determined by two independent observers using standardised landmarks. Measurement reproducibility was evaluated using intraclass correlation coefficients (ICCs) for both intra and interrater reliability (3-month interval). RESULTS:TT-TG distance values derived from conventional MRI were significantly smaller (13.4 ± 4.0 mm, 95% confidence interval [CI]: 12.2-14.6) compared to those from whole-leg rotational MRI (18.3 ± 4.4 mm [95% CI: 16.9-19.6]), yielding a mean difference of 4.8 ± 3.0 mm (95% CI: 3.9-5.8; p < 0.001). Both interrater (conventional MRI: ICC = 0.946 [95% CI: 0.901 - 0.971]; rotational MRI: ICC = 0.949 [95% CI: 0.899-0.973]) and intrarater reliability (conventional MRI: ICC = 0.995 [95% CI: 0.992-0.997]; rotational MRI: ICC = 0.991 [95% CI: 0.983-0.995]) were excellent across modalities. CONCLUSION:Conventional knee MRIs, performed with knee in slight flexion, are consistently smaller compared to those acquired in full extension whole-leg rotational MRI. Knee flexion, therefore, leads to a systematic underestimation of the TT-TG distance. Standardising knee position during imaging is essential to ensure accurate and comparable TT-TG assessments. LEVEL OF EVIDENCE:Level II, cohort study (diagnosis).

Stressröntgenaufnahmen stellen ein etabliertes Verfahren zur objektiven Beurteilung ligamentärer Instabilitäten des Kniegelenks dar. Sie ermöglichen unter standardisierten Bedingungen eine reproduzierbare und objektive Quantifizierung der Gelenkinstabilität bei Kreuzbandverletzungen (insbesondere dem hinteren Kreuzband) sowie der medialen und lateralen Kollateralbänder. Die Beurteilung der patellofemoralen Instabilität existiert eher experimental. Je nach vermuteter Instabilität kommen unterschiedliche Belastungsrichtungen und Flexionswinkel zum Einsatz: anteriorer oder posteriorer Stress bei Kreuzbandverletzungen (typischerweise in 90° Flexion) sowie Valgus- bzw. Varusstress bei Kollateralbandläsionen (in 0° und 20° Flexion). Die Belastung erfolgt entweder manuell oder mittels Apparaturen wie dem Telos-System mit definierter Krafteinleitung. Die daraus resultierenden Gelenkspaltveränderungen (medial bzw. lateral) oder Translationsdifferenzen der Tibia gegenüber dem Femur werden radiologisch erfasst und mit der Gegenseite verglichen. Klinisch relevante Instabilitäten lassen sich so objektiv nachweisen. Eine standardisierte Durchführung und exakte Lagerung sind entscheidend für die diagnostische Aussagekraft. Stressröntgenaufnahmen können somit einen wichtigen Beitrag zur differenzierten Diagnostik komplexer Bandverletzungen leisten und unterstützen die Therapieentscheidung hinsichtlich konservativer bzw. operativer Therapie; auch dienen sie der Qualitätskontrolle nach konservativer bzw. operativer Therapie.