Die laterale extraartikuläre Tenodese (LET) oder die Bandplastik des anterolateralen Ligamentes (ALL) haben sich in verschiedenen Techniken als sinnvolle Ergänzung zu einer Rekonstruktion des vorderen Kreuzbandes (VKB) etabliert. Die modifizierte Ellison-Technik weist gegenüber anderen Techniken insbesondere bei der Versorgung von Kindern und Jugendlichen einige entscheidende Vorteile auf. Neben der Distanz zu den Epiphysenfugen und dem damit geringen Risiko einer Verletzung derselben besteht weiterhin kein Risiko für einen Tunnelkonflikt mit der VKB-Bandplastik. Biomechanische Arbeiten zeigen zudem ein geringeres „overconstraint“ bezüglich der Innenrotationsfähigkeit im Vergleich zur modifizierten Lemaire-Technik. Der Zugang für die modifizierte Ellison-Tenodese erfolgt lateral über dem Tractus iliotibialis zwischen dem Tuberculum Gerdy und dem lateralen Epicondylus. Nach Darstellung des Tractus wird ein ca. 10 mm breiter Tractusstreifen am Tuberculum Gerdy abgelöst und bis direkt hinter den lateralen Epicondylus in Faserrichtung mobilisiert. Dieser Streifen wird dann unter dem lateralen Kollateralband (LCL) hindurchgeführt und am Tuberculum Gerdy reinseriert. Dies kann in verschiedenen Techniken erfolgen, in der Praxis hat sich die Verwendung von Fadenankern in Sinne einer „Onlay-Technik“ bewährt. Der Tractus wird distal an die Ellison-Tenodese adaptiert und weiter proximal darüber verschlossen. Die Nachbehandlung nach vorderer Kreuzbandplastik muss nicht speziell auf die Tatsache einer durchgeführten LET angepasst oder modifiziert werden.

Tibiofemoral (TF) rotation, the relative rotational alignment between femur and tibia in the axial plane at the level of the knee has been investigated as a parameter of joint alignment. Its influence on patellofemoral pathologies is largely unknown. Within this cross sectional study, it was hypothesized that TF rotation is increased in patients with symptomatic torsional femoral or tibial deformity and associated patellofemoral maltracking compared to healthy individuals. This single-center-study included patients with patellofemoral maltracking, including patellofemoral instability, who underwent tibial and/or femoral derotational osteotomy (surgery 2019–2024) and for whom preoperative torsional MRI was available. Torsion was measured according to Waidelich et al. and TF rotation defined as the angle between a tangent on the dorsal femoral condyles and a tangent on the dorsal tibial plateau. Positive values indicating external, negative values internal rotation. Tibial-tuberosity-trochlea-groove (TT-TG) distance was measured additionally. Interrater reliability was calculated between measurements of orthopaedic surgeons and musculoskeletal radiologists. Results were compared with those of a healthy control group that had previously been published. 86 cases were included (age 25.0 ± 9.0, 78

Anterior knee pain is a frequent symptom caused by disorders like patellofemoral pain syndrome or patella tendon tendinitis, which is commonly treated conservatively. The aim of the current study was to examine the effectiveness of a digital therapeutic (DT) versus German standard care through a prospective, randomized, multicenter controlled trial. Study participants were recruited in 9 orthopedic specialist centers diagnosed with anterior knee pain and a NPRS score of ≥ 4. Stratified randomization for n = 140 participants was conducted, assigning participants to the intervention group (exclusive use of DT) or the control group (standard care). Standard care included 1–3 prescriptions for physical therapy, while the DT consisted of a 90-day personalized exercise therapy program including educational content. The primary endpoints were pain measured by NPRS and functional impairment measured by the Kujala Score. The use of the DT compared to the standard care showed an improvement in clinical outcomes (NPRS = − 3.7 ± 2.67 and Kujala = 18.00 ± 13.96, both p < 0.001). Both pain and function improved clinically and statistically significantly compared to the control group (ANOVA: NPRS = − 1.64 ± 0.35, p < 0.001, Kujala = 9.26 ± 2.52, p < 0.01). The use of the DT showed significant improvements in pain and function compared to the current standard therapy. These results are highly relevant for clinical practice in the treatment decision-making for patients with anterior knee pain as the DT bridges effectively gaps in the healthcare systems.

The management of increased posterior tibial slope (PTS) in anterior cruciate ligament (ACL) injuries and insufficiencies and especially the indication for slope changing osteotomies has evolved to a highly discussed topic. The majority of available studies refer to cut-off values for the PTS and the number of previous ACL reconstructions in their indications. However, ACL injuries are a complex multifactorial problem, and available recommendations mainly ignore these highly individual factors, in their presence, and also in their complexity. Actually, many of the known risk factors for ACL insufficiency are also directly or indirectly associated with PTS. Therefore, the purpose of this paper is to propose a whole new way of thinking about complex ACL treatment strategies by integrating the PTS in a comprehensive approach of individual risk assessment and decision making. It is inspired by an established risk stratification system in a completely different but also very comparable field: avalanches. It is ultimately based on the thorough analysis of individual risk factors and accompanying circumstances on the one hand, and the standardized measured PTS on the other hand. These then define a point on a heat map (in a coordinate system) which, through the underlying colour, reflects the strength of the recommendation for a slope correction. This is to introduce The Avalanche Concept.

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.

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.

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.

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.

Numerous functional factors may interactively contribute to the course of self-report functional abilities after anterior cruciate ligament (ACL)-reconstruction. This study purposes to identify these predictors using exploratory moderation-mediation models in a cohort study design. Adults with post unilateral ACL reconstruction (hamstring graft) status and who were aiming to return to their pre-injury type and level of sport were included. Our dependent variables were self-reported function, as assessed by the the KOOS subscales sport (SPORT), and activities of daily living (ADL). The independent variables assessed were the KOOS subscale pain and the time since reconstruction [days]. All other variables (sociodemographic, injury-, surgery-, rehabilitation-specific, kinesiophobia (Tampa Scale of Kinesiophobia), and the presence or absence of COVID-19-associated restrictions) were further considered as moderators, mediators, or co-variates. Data from 203 participants (mean 26 years, SD 5 years) were finally modelled. Total variance explanation was 59% (KOOS-SPORT) and 47% (KOOS-ADL). In the initial rehabilitation phase (< 2 weeks after reconstruction), pain was the strongest contributor to self-report function (KOOS-SPORT: coefficient: 0.89; 95%-confidence-interval: 0.51 to 1.2 / KOOS-ADL: 1.1; 0.95 to 1.3). In the early phase (2-6 weeks after reconstruction), time since reconstruction [days] was the major contributor (KOOS-SPORT: 1.1; 0.14 to 2.1 / KOOS-ADL: 1.2; 0.43 to 2.0). Starting with the mid-phases of the rehabilitation, self-report function was no longer explicitly impacted by one or more contributors. The amount of rehabilitation [minutes] is affected by COVID-19-associated restrictions (pre-versus-post: - 672; - 1264 to - 80 for SPORT / - 633; - 1222 to - 45 for ADL) and by the pre-injury activity scale (280; 103 to 455 / 264; 90 to 438). Other hypothesised contributors such as sex/gender or age were not found to mediate the time or pain, rehabilitation dose and self-report function triangle. When self-report function is rated after an ACL reconstruction, the rehabilitation phases (early, mid, late), the potentially COVID-19-associated rehabilitation limitations, and pain intensity should also be considered. As, for example, pain is the strongest contributor to function in the early rehabilitation phase, focussing on the value of the self-report function only may, consequently, not be sufficient to rate bias-free function.

Wann immer möglich, sollte dem Versuch der Meniskusrekonstruktion der Vorzug gegenüber der Resektion gegeben werden. Dieser Videobeitrag soll Tipps zur praktischen Durchführung und Hilfen zur Fehlervermeidung bei der Meniskusnaht anhand der Rekonstruktion eines Innenmeniskuskorbhenkelrisses geben.

Cartilage regeneration with cell-free matrices has developed from matrix-associated autologous cartilage cell transplantation (MACT) over ten years ago. Adjustments to the legal framework and higher hurdles for cell therapy have led to the procedures being established as an independent alternative to MACT. These procedures, which can be classified as matrix-induced autologous cartilage regeneration (MACR), all rely on the chemotactic stimulus of a cross-linked matrix, which mostly consists of collagens. Given the example of a commercially available type I collagen hydrogel, the state of clinical experience with MACR shall be summarized and an outlook on the development of the method shall be provided. It has been demonstrated in the clinical case series summarized here over the past few years that the use of the matrix is not only safe but also yields good clinical-functional and MR-tomographic results for both small (~ 10 mm) and large (> 10 mm) focal cartilage lesions. Depending on the size of the defect, MACR with a collagen type I matrix plays an important role as an alternative treatment method, in direct competition with both: microfracture and MACT.

Objectives Elevated serum levels of chromium and cobalt ions in metal-on-metal (MoM) bearing surfaces is a well-known phenomenon in total hip arthroplasty. However, few studies have addressed this issue in complex primary and revision knee arthroplasty using a MoM hinged mechanism, and no study, to our knowledge, has investigated knees with MoM hinges in patients without megaprostheses (tumor prostheses).

Fragestellung Minimalinvasive Verfahren werden immer beliebter, um die Rehabilitation und die Fast-track-Chirurgie der gesamten Hüftendoprothese (THA) zu erleichtern. Die NANOS (Smith + Nephew)-Schenkelhalsprothese wurde entwickelt, um ein System mit metaphysären Verankerung und Lastverteilung zu schaffen. Das Implantat erfordert nur eine minimale Knochenresektion. Diese prospektive, multizentrische Beobachtungsstudie wurde durchgeführt, um die langfristige Sicherheit und Wirksamkeit des NANOS-Hüftschafts zu bestimmen. Es werden Fünfjahresergebnisse einer geplanten 10-Jahres-Analyse vorgestellt.

BACKGROUND:There is a clear tendency towards cementless acetabular components in primary total hip arthroplasty.OBJECTIVE:The aim of this study was to assess the long-term clinical and radiological outcome of titanium cementless acetabular cups when combined with a highly crosslinked polyethylene liner.METHODS:This study is a retrospective follow-up of 67 cups in 64 patients. Clinical outcomes were assessed using the Harris Hip Score. Radiolucent lines, osteolysis and loosening were assessed radiologically. Implant survival was determined using the Kaplan-Meier analysis.RESULTS:The average Harris Hip Score at follow-up was 80.3 ± 14.5. Signs of osteolysis were observed in 7.1% of the radiographs. No aseptic loosening of the cup was reported. Survival of the cup with aseptic loosening as an endpoint was 100%. A comparison with 19 other studies using the same material combination demonstrated very similar results. All manufacturers with available studies have at least one report of 100% survivorship at 10-year follow-up for their titanium cup and highly crosslinked polyethylene acetabular component combination with aseptic loosening as an endpoint.CONCLUSIONS:The data suggests that the rate of aseptic loosening of a titanium cup combined with a highly-crosslinked polyethylene liner at 10-year follow-up could be as low as 0%.

BACKGROUND:The Polarstem (Smith & Nephew, Baar, Switzerland) is a tapered straight stem, an implant with an excellent survival rate. Although the most recent annual report of the National Joint Registry in the United Kingdom also reports excellent survivorship for the cementless Polarstem, no prospective studies have been published focusing on both its efficacy and clinical performance. Therefore, the present study was designed to prospectively evaluate its functional and radiographic outcomes at midterm.METHODS:This prospective observational study conducted at 3 independent orthopaedic hospitals was designed to collect data in patients undergoing cementless primary total hip arthroplasty (THA). A total of 225 total hip arthroplasties (75 at each site) were performed. The predominant diagnosis was primary osteoarthritis. Anteroposterior and lateral radiographs were obtained at each follow-up (3 months, and 1, 3, and 5 years). Survivorship and the Harris Hip Score (HHS) and Western Ontario and McMaster Universities Index (WOMAC) were calculated.RESULTS:Subjects experienced statistically significant improvements from baseline in mean HHS (48.5 to 88.0, P < .01) and WOMAC scores (58.6 to 9.3, P < .01) at all intervals through 5 years. The stem survivorship was 99.6% at 5 years with stem revision due to any reason. There were no observed cases of mechanical failure of the stem or signs of radiographic loosening.CONCLUSIONS:A revision rate of the femoral stem for any reason of 0.4%, as well as good clinical results based on HHS and WOMAC scores, was noted at 5-year follow-up. Therefore, safety and efficacy of the cementless Polarstem at midterm follow-up is confirmed.

Cartilage defects of the knee remain a challenging problem in orthopedic surgery despite the ongoing improvements in regenerative procedures such as the autologous chondrocyte transplantation. Due to the lack of donor-site morbidity and the single-stage procedure cell-free scaffolds are an interesting alternative to cell-based procedures. But as currently mid- and long-term data are lacking, the aim of the present study was to present mid-term clinical, radiological and histological results of a cell-free collagen type I scaffolds for cartilage repair.