Wiley

In anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically ‘isolated’ ACL ruptures. Patients who underwent ACL reconstruction for complete ‘presumed isolated’ ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient’s characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests. Hundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus ‘ramp’ lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury. The incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment. III.

The use of a low anteroinferior (5:30 o’clock) portal for arthroscopic shoulder stabilization allows an anatomical refixation of the capsulolabral complex. This anteroinferior portal, however, penetrates the inferior subscapularis (SSC), which is criticized. Therefore, the aim of the study was to evaluate the functional and structural properties of the SSC in patients with anteroinferior shoulder stabilization. The hypothesis was that it does not harm the SSC by demonstrating full muscular function and imaging-based normal structure at a long-term follow-up. Twenty patients were examined (14 males and six females; mean age 37.0 years) retrospectively after a mean follow-up of 9.6 years. At final follow-up, clinical examination and clinical scores (ASES, Constant–Murley, WOSI, and Rowe score) were documented. Additionally, SSC strength was evaluated with a custom-made electronic force measurement plate. All patients underwent bilateral magnetic resonance imaging to assess structural integrity and fatty infiltration (grading according to Fuchs et al.) of the SSC. Furthermore, vertical and transversal (superior and inferior) diameters of the muscle and the muscle area in a parasagittal plane were measured. Clinical scores revealed good-to-excellent long-term results (ASES 92 points, Constant–Murley 82 points, WOSI 85 %, and Rowe 84 points). Force measurement in comparison with the contralateral side showed no significant (p > 0.05) differences for the ‘belly-press’ test (ipsilateral 102 N vs. contralateral 101 N) and the ‘lift-off’ test (73 vs. 69 N). There were also no significant differences between the mean diameters and the areas of the SSC muscle belly (vertical diameter ipsilateral 92 mm vs. contralateral 94 mm; superior transversal 28 vs. 29 mm; inferior transversal 34 vs. 34 mm; area 2336 vs. 2526 mm2). Arthroscopic labral repair with a low anteroinferior portal demonstrates no signs of structural and functional impairment of the SSC after 9.6 year follow-up. For clinical relevance, the lower part of the SSC can be penetrated for an optimal anchor placement in shoulder instabilities or Bankart fractures without concerns of a negative long-term effect on the SSC. Case series, Level IV.

Reconstruction of the posterior cruciate ligament (PCL) yields less satisfying results than anterior cruciate ligament reconstruction with respect to laxity control. Accurate tibial tunnel placement is crucial for successful PCL reconstruction using arthroscopic tibial tunnel techniques. A discrepancy between anatomical studies of the tibial PCL insertion site and surgical recommendations for tibial tunnel placement remains. The objective of this study was to identify the optimal placement of the tibial tunnel in PCL reconstruction based on clinical studies. In a systematic review of the literature, MEDLINE, EMBASE, Cochrane Review, and Cochrane Central Register of Controlled Trials were screened for articles about PCL reconstruction from January 1990 to September 2011. Clinical trials comparing at least two PCL reconstruction techniques were extracted and independently analysed by each author. Only studies comparing different tibial tunnel placements in the retrospinal area were included. This systematic review found no comparative clinical trial for tibial tunnel placement in PCL reconstruction. Several anatomical, radiological, and biomechanical studies have described the tibial insertion sites of the native PCL and have led to recommendations for placement of the tibial tunnel outlet in the retrospinal area. However, surgical recommendations and the results of morphological studies are often contradictory. Reliable anatomical landmarks for tunnel placement are lacking. Future randomized controlled trials could compare precisely defined tibial tunnel placements in PCL reconstruction, which would require an established mapping of the retrospinal area of the tibial plateau with defined anatomical and radiological landmarks. III.

To elaborate recommendations for sports participation following TKA among the members of the European Knee Associates (EKA). A prospective online survey was conducted among the members of the European Knee Associates (EKA). The European Knee Associates (EKA) are a section of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). The survey investigated recommendations for 47 sports disciplines. Possible answers were: allowed, allowed if experienced, not allowed, no opinion. The survey was conducted separately for 4 specific time frames: within 6 weeks after TKA; 6–12 weeks after TKA; 3–6 months after TKA; and more than 6 months after TKA. Consensus among the respondents was then analyzed. EKA members (N = 120) participated in the survey. A high level of consensus was reached for a recommendation to allow 5 different sports in the first 6 weeks after TKA, 7 sports 6–12 weeks after surgery, 14 sports 3–6 months after TKA, and 21 out of 47 activities 6 months after surgery. In the first 6 weeks after TKA walking, stair climbing, swimming, aqua fitness, and static cycling were recommended. Six to twelve weeks after TKA, cycling on level ground and yoga were recommended in addition to the aforementioned activities. Further sports activities recommended beyond 12 weeks after TKA were: tennis doubles, golf, fitness/weight lifting, aerobics, hiking, Nordic walking and sailing. The sport for which the recommendation was “not allowed” following TKA was squash. The number of sports recommended by EKA surgeons increases stepwise over the postoperative time frames. The findings are regarded as clinically relevant as they may serve as a basis for answering patient questions on timing and giving recommendations for the resumption of sports activities following standard primary TKA and should be individualized by surgeons for their patients’ expectations and goals. V.

The critical shoulder angle (CSA) has been implicated as a potential risk factor for failure following arthroscopic rotator cuff repair (RCR). However, there is conflicting evidence regarding the clinical usefulness of this measurement. Given these discrepancies and limited comparisons to clinical outcomes, the aim of the current study was to determine whether higher CSAs correlated with an increased retear rate after arthroscopic rotator cuff repair and to determine if any association between CSA and patient-reported outcomes (PROs) exists. It was hypothesized that there would be no correlation between CSA and retear rate or PROs after arthroscopic rotator cuff repair. A total of 164 patients who underwent arthroscopic RCR were retrospectively reviewed. CSA was measured for each patient. Patients were then divided into a retear group of 18 patients and a non-retear group of 146 patients. Patient-reported outcomes (PROs), including PROMIS 10 score, American Shoulder and Elbow Surgeons (ASES) score, Brophy score, and visual analog pain scores (VAS) were recorded post-operatively. The average CSA was 31.2 ± 4.5° for the retear group and 32.2 ± 4.7° for the non-retear group (n.s.). No correlations were found between CSA and PROMIS score (n.s.), ASES score (n.s.), Brophy score (n.s.), or VAS (n.s.). Critical shoulder angle had no correlation to retear rate or patient-reported outcomes. CSA should not be used as a clinical predictor to assess rotator cuff retear risk after arthroscopic RCR. Level III.

Open-wedge high tibial osteotomy (HTO) is becoming increasingly popular for the treatment of varus gonarthrosis in the active patient. The various implants used in HTO differ with regard to its design, the fixation stability and osteotomy technique. It is assumed that the combination of a plate fixator with a biplanar, v-shaped osteotomy supports bone healing. So far, there are no biomechanical studies that quantify the stabilizing effect of a biplanar versus uniplanar osteotomy. We hypothesized that a significant increase in primary stability of bone-implant constructs is achieved when using a biplanar as opposed to a uniplanar osteotomy. Twenty-four fresh-frozen human tibiae were mounted in a metal cylinder, and open-wedge osteotomy (12 mm wedge size) was performed in a standardized fashion. Proximal and distal tibial segments were marked with tantalum markers of 0.8 mm diameter. Two different plates with locking screws were used for fixation: a short spacer plate (group 1, n = 12) and a plate fixator (group 2, n = 12). In six specimens of each group, a biplanar V-shaped osteotomy with a 110° angulated anterior cut behind the tuberosity parallel to the ventral tibial shaft axis was performed. In the remaining six specimens of each group, a simple uniplanar osteotomy was performed in an oblique fashion. Axial compression of the tibiae was performed using a material testing machine under standardized alignment of the loading axis. Load-controlled cyclical staircase loading tests were performed. The specimens were radiographed simultaneously in two planes together with a biplanar calibration cage in front of a film plane with and without load after each subcycle. Radiostereometry allowed for serial quantification of plastic and elastic micromotion at the osteotomy site reflecting the stability provided by the combination of implant and osteotomy technique. No significant additional stabilizing effect of a biplanar osteotomy in craniocaudal and mediolateral plane was found. However, additional stability was achieved in anteroposterior (AP) and all rotational planes in those specimens fixated with a short spacer plate. In this biomechanical set-up with axial load, the additional stabilizing effect of a biplanar osteotomy did not come into effect in the presence of a long and rigid plate fixator. However, biplanar osteotomy increased the fixation stability significantly in AP and rotational planes when a short spacer plate was used. Clinically, the biplanar osteotomy promotes bone healing regardless of the implant used. Biomechanically, biplanar osteotomy is advantageous for shorter plate designs to increase primary stability of the bone-implant construct.

Patellar dislocation is a condition that is often reduced by itself or through closed manipulation from a trained professional. In this case of a traumatic lateral patellar dislocation, the patella was caught through the rupture in the lateral retinaculum, as is seen in Boutonniere-like lesions. Reduction of the dislocated patella was obtained by arthroscopic reduction. Level of evidence V.

This paper focuses on the anatomical attachment of the medial meniscus. Detailed anatomical dissections have been performed and illustrated. Five zones can be distinguished in regard to the meniscus attachments anatomy: zone 1 (of the anterior root), zone 2 (anteromedial zone), zone 3 (the medial zone), zone 4 (the posterior zone) and the zone 5 (of the posterior root). The understanding of the meniscal anatomy is especially crucial for meniscus repair but also for correct fixation of the anterior and posterior horn of the medial meniscus.

The primary purpose of this study was to investigate the role the ligamentum teres has in providing hip stability using a biomechanical model. The second purpose was to review arthroscopic findings in those with a complete ligamentum teres rupture and question them regarding instability to determine how clinical findings related to the biomechanical model. A string model was created to examine ligamentum teres excursion during various hip positions. A retrospective review of 350 consecutive surgical patients identified 20 subjects with a complete ligamentum teres rupture that was not repaired at the time of surgery. The model found the ligamentum teres to have the greatest excursion when the hip was externally rotated in flexion (ER/FLEX) and internally rotated in extension (IR/EXT). During operative assessment, it was noted that all 20 subjects had laxity during dynamic impingement testing when their hip was in a position of ER/FLEX. Nine (45%) of the 20 subjects with ligamentum teres rupture were available for follow-up (mean 31 months post-op). Five out of these 9 subjects noted instability: 5 of 9 with squatting (ER/FLEX) and 4 of 9 with crossing one leg behind of the other (IR/EXT). These 5 subjects had osseous risk factors that compromised hip stability including inferior acetabular insufficiency. The ligamentum teres may contribute to hip stability when the hip is in ER/FLEX and IR/EXT. Individuals with osseous risk factors for instability, including inferior acetabular insufficiency, may have instability with squatting (ER/FLEX) and crossing one leg behind of the other (IR/EXT). IV.