Patellofemoral cartilage defects are acceptable in patients undergoing high tibial osteotomy for medial osteoarthritis of the knee.

BACKGROUND: Patients suffering cartilage defects of the medial compartment with underlying varus deformity do benefit from high tibial osteotomy (HTO) even in the long term. Nonetheless, kinematic and geometric changes especially in the patellofemoral joint have been described. Purpose of the present study was to evaluate the influence of patellofemoral cartilage defects detected during the diagnostic arthroscopy and their influence on HTO's postoperative outcome. METHODS: Ninety patients with a mean follow-up of 10.08 ± 2.33 years after surgery were included. Patients were divided into four groups according to their cartilage status in the patellofemoral joint (A = no defects, B = isolated lesions of the patella, C = isolated lesions of the trochlea, D = kissing lesions). Functional outcome was evaluated before surgery and about ten years thereafter by relying on the IKDC, Lysholm, and KOOS scores. Radiological parameters were assessed pre- and six weeks postoperatively. RESULTS: In groups A to D, the HTO led to significant patellar distalisation in the sagittal view, with the mean indices remaining at or above the limit to a patella baja. All patients in all groups profited significantly from HTO (higher Lysholm score, lower VAS p < 0.001), patients in group D had the lowest outcome scores. Patella height negatively influenced outcome scores in group C (Blackburne-Peel-Index-VAS p = 0.033) and D (Caton-Deschamps-Index-Tegner p = 0.018), a larger valgus correction was associated with lower outcome scores in group D (Lysholm p = 0.044, KOOSpain 0.028, KOOSQOL p = 0.004). CONCLUSION: Long-term results of HTO for varus medial compartment osteoarthritis remain good to excellent even in the presence of patellofemoral defects. Overcorrection should be avoided. Distal biplanar HTO should be considered for patients presenting trochlear or kissing lesions of the patellofemoral joint. TRIAL REGISTRATION: DRKS00015733 in the German Registry of Clinical Studies.

10-Year Survival Rates After High Tibial Osteotomy Using Angular Stable Internal Plate Fixation: Case Series With Subgroup Analysis of Outcomes After Combined Autologous Chondrocyte Implantation and High Tibial Osteotomy.

BACKGROUND: Good-to-excellent midterm results after high tibial osteotomy (HTO) to treat medial compartment cartilage defects or osteoarthritis (OA) have been published, but little is known about long-term survival rates in terms of conversion to total knee arthroplasty (TKA) using angular stable internal plate fixation. PURPOSE: To determine TKA-free survival rates and functional and radiological outcomes at 10 years after HTO. A subgroup analysis of patients who underwent combined HTO and autologous cartilage implantation (ACI) was also performed. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included were 125 patients with a mean follow-up of 9.90 ± 2.25 years; 90 patients underwent HTO for medial OA, and 35 patients underwent ACI and HTO for medial focal cartilage defects. Functional outcome measures included visual analog scale (VAS) for pain, Lysholm, International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and KOOS4 (average of 4 KOOS subscales: Pain, Symptoms, Sport, and Quality of Life). Radiological outcomes included lateral distal femoral angle, medial proximal tibial angle, and joint line convergence angle. RESULTS: Overall, 16 patients required conversion to TKA at a mean 86.75 ± 25.73 months (10-year survival rate, 87.2%). Only 2 patients in the HTO+ACI subgroup required a conversion to TKA (10-year survival rate, 94.3%). The complication rate for all patients was 8.8%. In both the HTO and HTO+ACI subgroups, VAS pain levels decreased and Lysholm scores increased significantly from pre- to postoperatively (P < .001). A higher preoperative Tegner score led to a significantly lower risk for conversion to TKA (P = .001), and a preoperative body mass index of ≥35 was associated with a significantly higher risk (P = .019), as was female sex (P = .046). Radiological parameters remained within physiological ranges. The postoperative joint line conversion angle did correlate with postoperative functional outcome but not with TKA conversion. CONCLUSION: Long-term results of HTO for medial compartment OA or cartilage defects with underlying varus deformity were good to excellent. In particular, patients who underwent HTO+ACI presented excellent long-term survival rates. HTO, therefore, delays or prevents TKA implantation, especially in young, active patients with medial compartment damage.

Influence of surgical stabilization of clavicle fractures in multiply-injured patients with thoracic trauma.

Thoracic trauma has decisive influence on the outcome of multiply-injured patients and is often associated with clavicle fractures. The affected patients are prone to lung dysfunction and multiple organ failure. A multi-center, retrospective analysis of patient records documented in the TraumaRegister DGU was performed to assess the influence of surgical stabilization of clavicle fractures in patients with thoracic trauma. A total of 3,209 patients were included in the analysis. In 1362 patients (42%) the clavicle fracture was treated operatively after 7.1 ± 5.3 days. Surgically treated patients had a significant reduction in lung failure (p = 0.013, OR = 0.74), multiple organ failure (p = 0.001, OR = 0.64), intubation time (p = 0.004; -1.81 days) and length of hospital stay (p = 0.014; -1.51 days) compared to non-operative treatment. Moreover, surgical fixation of the clavicle within five days following hospital admission significantly reduced the rates of lung failure (p = 0.01, OR = 0.62), multiple organ failure (p = 0.01, OR = 0.59) and length of hospital stay (p = 0.01; -2.1 days). Based on our results, multiply-injured patients with thoracic trauma and concomitant clavicle fracture may benefit significantly from surgical stabilization of a clavicle fracture, especially when surgery is performed within the first five days after hospital admission.

Long-standing pubic-related groin pain in professional academy soccer players: a prospective cohort study on possible risk factors, rehabilitation and return to play.

BACKGROUND: Despite being a common overuse entity in youth soccer, scientific data on risk factors, rehabilitation and return to play for long-standing pubic-related groin pain is still rare. The current prospective cohort study aims to evaluate potential risk-factors, propose a criteria-based conservative rehabilitation protocol and assess return-to-play outcomes among professional youth soccer players suffering from long-standing pubic-related groin pain. METHODS: Male soccer players with long-standing (> 6 weeks) pubic-related groin pain from a professional soccer club's youth academy were analyzed for possible risk factors such as age, team (U12 - U23), younger/older age group within the team, position and preinjury Functional movement score. All injured players received a conservative, standardized, supervised, criteria-based, 6-level rehabilitation program. Outcome measures included time to return to play, recurrent groin pain in the follow-up period and clinical results at final follow-up two years after their return to play. RESULTS: A total of 14 out of 189 players developed long-standing pubic-related groin pain in the 2017/2018 season (incidence 7.4%). The average age of the players at the time of the injury was 16.1 ± 1.9 years. Risk factor analysis revealed a significant influence of the age group within the team (p = .007). Only players in the younger age group were affected by long-standing pubic-related groin pain, mainly in the first part of the season. Injured players successfully returned to play after an average period of 135.3 ± 83.9 days. Only one player experienced a recurrence of nonspecific symptoms (7.1%) within the follow-up period. The outcome at the 24-month follow-up was excellent for all 14 players. CONCLUSIONS: Long-standing pubic-related groin pain is an overuse entity with a markedly high prevalence in youth soccer players, resulting in a relevant loss of time in training and match play. In particular, the youngest players in each team are at an elevated risk. Applying a criteria-based rehabilitation protocol resulted in an excellent return-to-play rate, with a very low probability of recurrence. TRIAL REGISTRATION: The trial was retrospectively registered under DRKS00016510 in the German Clinical Trials Register on 19.04.2021.

Efficacy of a semirigid ankle brace in reducing mechanical ankle instability evaluated by 3D stress-MRI.

BACKGROUND: Novel imaging technologies like 3D stress-MRI of the ankle allow a quantification of the mechanical instability contributing to chronic ankle instability. In the present study, we have tested the efficacy of a semirigid ankle brace on joint congruency in a plantarflexion/supination position with and without load. METHODS: In this controlled observational study of n = 25 patients suffering from mechanical ankle instability, a custom-built ankle arthrometer implementing a novel 3D-stress MRI technique was used to evaluate the stabilizing effect of an ankle brace. Three parameters of joint congruency (i.e., 3D cartilage contact area fibulotalar, tibiotalar horizontal and tibiotalar vertical) were measured. The loss of cartilage contact area from neutral position to a position combined of 40° of plantarflexion and 30° of supination without and with axial load of 200 N was calculated. A semirigid ankle brace was applied in plantarflexion/supination to evaluate its effect on joint congruence. Furthermore, the perceived stability of the brace during a hopping task was analyzed using visual analogue scale (VAS). RESULTS: The application of a semirigid brace led to an increase in cartilage contact area (CCA) when the foot was placed in plantarflexion and supination. This effect was visible for all three compartments of the upper ankle joint (P < 0.001; η2 = 0.54). The effect of axial loading did not result in significant differences. The subjective stability provided by the brace (VAS 7.6/10) did not correlate to the magnitude of the improvement of the overall joint congruency. CONCLUSIONS: The stabilizing effect of the semirigid ankle brace can be verified using 3D stress-MRI. Providing better joint congruency with an ankle brace may reduce peak loads at certain areas of the talus, which possibly cause osteochondral or degenerative lesions. However, the perceived stability provided by the brace does not seem to reflect into the mechanical effect of the brace. Trial registration The study protocol was prospectively registered at the German Clinical Trials Register (#DRKS00016356).

Thromboembolic complications among multiple injured patients with pelvic injuries: identifying risk factors for possible patient-tailored prophylaxis.

BACKGROUND: Patients with pelvic and/or acetabular fractures are at high risk of developing thromboembolic (TE) complications. In our study we investigate TE complications and the potential negative effects of concomitant pelvic or acetabular injuries in multiple injured patients according to pelvic/acetabular injury severity and fracture classification. METHODS: The TraumaRegister DGU® was analyzed between 2010 and 2019. Multiple injured patients with pelvic and/or acetabular fractures with ISS ≥ 16 suffering from TE complications were identified. We conducted a univariate and multivariate analysis with TE events as independent variable to examine potential risk factors and contributing factors. RESULTS: 10.634 patients met our inclusion criteria. The overall TE incidence was 4.9%. Independent risk factors for the development of TE complications were sepsis, ≥ 10 operative interventions, mass transfusion (≥ 10 PRBCs), age ≥ 65 years and AISAbdomen ≥ 3 (all p < 0.001). No correlation was found for overall injury severity (ISS), moderate traumatic brain injury, additional injury to lower extremities, type B and C pelvic fracture according to Tile/AO/OTA and closed or open acetabular fracture. CONCLUSIONS: Multiple injured patients suffering from pelvic and/or acetabular fractures are at high risk of developing thromboembolic complications. Independent risk factors for the development of thromboembolic events in our study cohort were age ≥ 65 years, mass transfusion, AISAbdomen ≥ 3, sepsis and ≥ 10 surgery procedures. Among multiple injured patients with acetabular or pelvic injuries the severity of these injuries seems to have no further impact on thromboembolic risk. Our study, however, highlights the major impact of early hemorrhage and septic complications on thromboembolic risk in severely injured trauma patients. This may lead to individualized screening examinations and a patient-tailored thromboprophylaxis in high-risk patients for TE. Furthermore, the number of surgical interventions should be minimized in these patients to reduce thromboembolic risk.

Arthroscopic Bankart repair with an individualized capsular shift restores physiological capsular volume in patients with anterior shoulder instability.

PURPOSE: Capsular volume reduction in the context of anterior arthroscopic shoulder stabilization represents an important but uncontrolled parameter. The aim of this study was to analyse capsular volume reduction by arthroscopic Bankart repair with an individualized capsular shift in patients with and without ligamentous hyperlaxity compared to a control group. METHODS: In the context of a prospective controlled study, intraoperative capsular volume measurements were performed in 32 patients with anterior shoulder instability before and after arthroscopic Bankart repair with an individualized capsular shift. The results were compared to those of a control group of 50 patients without instability. Physiological shoulder joint volumes were calculated and correlated with biometric parameters (sex, age, height, weight and BMI). RESULTS: Patients with anterior shoulder instability showed a mean preinterventional capsular volume of 35.6 ± 10.6 mL, which was found to be significantly reduced to 19.3 ± 5.4 mL following arthroscopic Bankart repair with an individualized capsular shift (relative capsular volume reduction: 45.9 ± 21.9%; P < 0.01). Pre-interventional volumes were significantly greater in hyperlax than in non-hyperlax patients, while post-interventional volumes did not differ significantly. The average shoulder joint volume of the control group was 21.1 ± 7.0 mL, which was significantly correlated with sex, height and weight (P < 0.01). Postinterventional capsular volumes did not significantly differ from those of the controls (n.s.). CONCLUSION: Arthroscopic Bankart repair with an individualized capsular shift enabled the restoration of physiological capsular volume conditions in hyperlax and non-hyperlax patients with anterior shoulder instability. Current findings allow for individual adjustment and intraoperative control of capsular volume reduction to avoid over- or under correction of the shoulder joint volume. Future clinical studies should evaluate, whether individualized approaches to arthroscopic shoulder stabilization are associated with superior clinical outcome.

Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®.

BACKGROUND: Major trauma often comprises fractures of the thoracolumbar spine and these are often accompanied by relevant thoracic trauma. Major complications can be ascribed to substantial simultaneous trauma to the chest and concomitant immobilization due to spinal instability, pain or neurological dysfunction, impairing the respiratory system individually and together. Thus, we proposed that an early stabilization of thoracolumbar spine fractures will result in significant benefits regarding respiratory organ function, multiple organ failure and length of ICU / hospital stay. METHODS: Patients documented in the TraumaRegister DGU®, aged ≥16 years, ISS ≥ 16, AISThorax ≥ 3 with a concomitant thoracic and / or lumbar spine injury severity (AISSpine) ≥ 3 were analyzed. Penetrating injuries and severe injuries to head, abdomen or extremities (AIS ≥ 3) led to patient exclusion. Groups with fractures of the lumbar (LS) or thoracic spine (TS) were formed according to the severity of spinal trauma (AISspine): AISLS = 3, AISLS = 4-5, AISTS = 3 and AISTS = 4-5, respectively. RESULTS: 1740 patients remained for analysis, with 1338 (76.9%) undergoing spinal surgery within their hospital stay. 976 (72.9%) had spine surgery within the first 72 h, 362 (27.1%) later on. Patients with injuries to the thoracic spine (AISTS = 3) or lumbar spine (AISLS = 3) significantly benefit from early surgical intervention concerning ventilation time (AISLS = 3 only), ARDS, multiple organ failure, sepsis rate (AISTS = 3 only), length of stay in the intensive care unit and length of hospital stay. In multiple injured patients with at least severe thoracic spine trauma (AISTS ≥ 4) early surgery showed a significantly shorter ventilation time, decreased sepsis rate as well as shorter time spend in the ICU and in hospital. CONCLUSIONS: Multiply injured patients with at least serious thoracic trauma (AISThorax ≥ 3) and accompanying spine trauma can significantly benefit from early spine stabilization within the first 72 h after hospital admission. Based on the presented data, primary spine surgery within 72 h for fracture stabilization in multiply injured patients with leading thoracic trauma, especially in patients suffering from fractures of the thoracic spine, seems to be beneficial.

Improved clinical outcome after medial open-wedge osteotomy despite cartilage lesions in the lateral compartment.

High tibial medial open-wedge osteotomy (HTO) is an established treatment option for cartilage lesions in the medial compartment. It was this study's aim to evaluate the effect of asymptomatic single or kissing lesions in the lateral compartment on functional outcome after medial open-wedge osteotomy. A total of 156 patients were enrolled in this retrospective study. All patients underwent HTO due to a varus deformity and a symptomatic cartilage lesion or osteoarthritis in the medial compartment. We acquired preoperative Lysholm and VAS Scores. Each open-wedge osteotomy was preceded by diagnostic arthroscopy to ensure the compartments were thoroughly documented and diagnosed. Cartilage lesions in the lateral compartment were evaluated, and three groups created according to their individual characteristics: group A (no cartilage lesion, n = 119), group B (single cartilage lesion, n = 16) and group C (kissing lesions, n = 21). Cartilage lesions were graded according to the Outerbridge classification, The functional postoperative outcome was determined by relying on several parameters (VAS Score, Lysholm, KOOS, WOMAC Score). Pre- and postoperative long-leg axis views were analyzed via special planning software (mediCAD, Hectec GmbH Germany). Mean follow-up was at 69.0 ± 30.3 months after surgery (range 22 to 121 months). There were no significant differences between the three groups in the correction angle chosen (p = 0.16). Regarding the outcome parameters, group A attained the best results in the WOMACpain Score (p = 0.03) and WOMACfunction Score (p = 0.05). A higher Outerbridge-Score of cartilage lesions in the lateral compartment was associated with a higher (i.e., worse) WOMACpain Score (p = 0.018) and WOMACfunction Score (p = 0.033). In all the groups (A, B, and C), HTO led to a significant improvement in the Lysholm Score (p < 0.001) and to a decrease in pain level (VAS Score; p < 0.001). Conclusion: Valgus high tibial osteotomy leads to reduced pain and improved functional outcome scores, even in patients with pre-existing asymptomatic single or corresponding cartilage lesions in the lateral compartment. In case of severe cartilage lesions in the lateral compartment, surgeons should consider that clinical outcome worsens depending on the Outerbridge Score.

Pelvic fractures in severely injured children: Results from the TraumaRegister DGU.

Injuries in the pelvic region in children and adolescents are very rare and often associated with a high energy trauma. Aim of this prospective multicenter study was, by analyzing the data from the TraumaRegister Deutsche Gesellschaft für Unfallchirurgie (TR-DGU), to evaluate any correlation between the severity of pelvic fractures and resulting mortality in different age groups.These study findings are based on a large pool of data retrieved from the prospectively-setup pelvic trauma registry established by the German Trauma Society (DGU) and the German Section of the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) International in 1991. The registry provides data on all patients suffering pelvic fractures within a 14-year time frame at any 1 of the 23 level 1 trauma centers contributing to the registry. The analysis covers 4 age groups ranging from 0 to 17 years, covering different factors regarding pelvic fractures and their treatment.We identified a total of 9684 patients including 1433 pelvic fractures in children aged ≤17 years. Those patients were divided into 4 subgroups according to the patients' age (groups A-D) and according to the fracture severity (group 1 =  Abbreviated Injury Scale (AIS) score pelvis ≤2, and group 2 = AIS pelvis ≥3). The mortality in group 1 was 8.8% with a RISC (Revised Injury Severity Score) II of 8.6%, standard mortality rate (SMR) of 1.02 and 7.2% in group 2 with an RISC II of 9.9% (SMR 0.73). In pelvic factures of Type A (Tile classification of pelvic fractures), an SMR of 0.76 was recorded, in Type B fractures the SMR was 0.65, and in Type C fractures 0.79. Severe pelvic injuries (AIS pelvis ≥2) were associated with a higher rate of whole body computer tomograph (CT) scans (1-5 years: 80%, 6-10 years 81.8%, 11-14 years 84.7%, and 15-17 years 85.6%). The rate of pelvic surgery rose with the pelvic injury's severity (AIS 2: 7.6%, AIS 3: 35%, AIS 4: 65.6%, AIS 5 61.5%). We observed higher rates of preclinical and initial clinical hypotension defined as Riva-Rocci (RR) <90 mmHG) as well as of preclinical fluid application in all age groups. The presence of a pelvic injury was associated with a higher rate of severe abdominal injuries with an AIS of ≥3 (25.1% vs. 14.6%) and of severe thorax injuries with an AIS≥3 (43.6% vs. 28.6%).We have been able to analyze an enormous number of pelvic fractures in children and adolescents including different age groups by relying on data from the TR-DGU. Mortality seems to be associated with the severity of the pelvic injury, but is lower than the RISC II score's prognosis.

Sport-specific outcomes after isolated meniscal repair: a systematic review.

PURPOSE: The purpose of this systematic review was to assess sport-specific outcomes after repair of isolated meniscal tears. METHODS: A systematic electronic search of the MEDLINE and Cochrane database was performed in May 2016 to identify studies that reported sport-specific outcomes after isolated meniscal repair. Included studies were abstracted regarding study characteristics, patient demographics, surgical technique, rehabilitation, and outcome measures. The methodological quality of the included studies was assessed with the Coleman Methodology Score (CMS). RESULTS: Twenty-eight studies with a total of 664 patients met the inclusion criteria. The methodological quality of the included studies was moderate, with a mean CMS of 69.7 ± 8.3. The mean patient age was 26 ± 7.2 years and 71% of patients were male. Mean preoperative Tegner score improved from 3.5 ± 0.3 to 6.2 ± 0.8 postoperatively. Comparing preinjury and postoperative Tegner scores, comparable values were observed (6.3 ± 1.1 and 5.7 ± 0.8, respectively). Return to sports on the preinjury level was achieved in 89%. Mixed-level populations returned to their preinjury activity level in 90% and professional athletes in 86%. Mean delay of return to sports varied between 4.3 and 6.5 months, with comparable results between professional and mixed-level athletes. The pooled failure rate was 21%. The failure rate was lower in professional athletes compared to mixed-level athletes (9% vs. 22%). CONCLUSION: This systematic review suggests that isolated repair of meniscal tears results in good to excellent sport-specific outcomes and a high return to sports rate in both recreational and professional athletes. The failure rate is comparable to systematic reviews not focusing on sportive patients. LEVEL OF EVIDENCE: Level IV systematic review of Level I to Level IV studies.

Focal metallic inlay resurfacing prosthesis for the treatment of localized cartilage defects of the femoral condyles: a systematic review of clinical studies.

PURPOSE: To systematically review the results of focal metallic inlay resurfacing prosthesis for the treatment of isolated cartilage defects of the femoral condyles. METHODS: A systematic electronic search of the PubMed database and the Cochrane Library was performed in April 2017 to identify studies that reported clinical or radiographic outcome of focal metallic inlay resurfacing prosthesis for the treatment of isolated cartilage defects of the femoral condyles. Included studies were abstracted regarding study characteristics, patient demographics, prosthetic device and location, indications and contraindications, and outcome measures. Outcome of interest included functional outcome scores, radiographic measures, complications, re-operations, and conversion to arthroplasty. The methodologic quality of the included studies was assessed with the Coleman Methodology Score. RESULTS: Six studies with a total of 186 patients met the inclusion criteria. Five studies were level IV evidence, and one was level III. The methodologic quality of the included studies was good, with a mean Coleman Methodology Score of 78. Two different implants were used: the HemiCAP® (five studies; 66% of study group) and UniCAP® (one study; 34%) implant. The mean age was 46-54 years, and the mean follow-up was 24 months to 7 years. Pre- and post-operative outcome scores were compared in all six studies, and five studies reported significant improvements at the final follow-up for all scores (objective und functional KSS, KOOS, WOMAC, Tegner, HSS Knee and Function score, SF-36 and SF-12 physical component score) except for the SF-36 and SF-12 mental component score. Progression of osteoarthritis was analysed using the Kellgren-Lawrence grading in three studies (30% of study group), with two studies reporting significant progression. The OARSI grading system was analysed in one study with no significant progression. The overall conversion rate to arthroplasty was 22% with considerable differences between the two implants: 9% for HemiCAP® and 47% for UniCAP®. CONCLUSIONS: Focal metallic inlay resurfacing prosthesis seems to be a viable option for a carefully selected group of patients. Significant improvement in knee function and pain was observed in most patients. Uncertainty remains with regard to progression of osteoarthritis because of conflicting results and inconsistent reporting. One out of five patients has to be converted to arthroplasty after an average of 4 years. However, compared to the UniCAP® implant, considerable lower conversion rates were reported for the smaller HemiCAP® implant. LEVEL OF EVIDENCE: Systematic review of level III and IV studies, Level IV.

Customized post-operative alignment improves clinical outcome following medial open-wedge osteotomy.

PURPOSE: High tibial osteotomy (HTO) has gained more importance in the treatment of cartilage damage or osteoarthritis of the medial compartment with concurrent varus deformity. Concerning the extent of axis correction, various different views exist. The aim of this study was to evaluate the effect of the size of axis correction on functional outcome in patients undergoing a valgus HTO. METHODS: From 2005 to 2013, 156 patients with an underlying varus deformity and cartilage damages or unicompartimental osteoarthritis of the medial compartment were treated by HTO. Retrospectively patients were allocated into three different groups according to the degree of axis correction. For this purpose, three adjacent areas, respectively, comprising 5% of the tibial plateau were defined. Limits of those areas were set as follows: with the medial border representing the 0% point and the lateral border representing the 100 point, the three areas were separated according to their limiting intersection points (group A 50-55%, group B 55-60%, group C > 60%). For comparison of the functional outcomes, standardized measures and scores were used (pre-OP: VAS, Lysholm; post-OP: VAS, Lysholm, KOOS). Analysis of the pre- and post-operatively recorded X-rays was effected by means of a planning software (mediCAD, Hectec GmbH, Germany), and statistical analysis was carried out using SPSS Statistics 21.0 (IBM Corp., Armonk, USA). A p value of 0.05 was considered statistically significant. RESULTS: Thirty-nine patients were allocated to group A, 50 patients to group B and 67 to group C. Pre-operatively, patients in each group were of a homogenous constitution. In the groups A-C, HTO proved to reduce the VAS score and to increase the Lysholm score (p < 0.001). Regarding outcome parameters, group A showed significantly better results in terms of increased Lysholm (p = 0.049) and KOOS pain score (p = 0.043). In patients treated by HTO and ACI implantation for medial compartment lesions, the best results were achieved in group A which was of statistical significance in comparison of the Lysholm (p = 0.006) and VAS score (p = 0.045) of groups A and C. In this subgroup, the size of the post-operative valgus angle significantly correlated with the final VAS score (PC 0.364; p = 0.013), final Lysholm score (PC - 0.390; p = 0.007) and KOOS4 (PC - 0.356; p = 0.014). CONCLUSION: HTO for varus deformity in patients with concomitant cartilage damage or osteoarthritis of the medial compartment is a reliable treatment option with satisfying functional outcome. Precise pre-operative planning regarding individual factors in each patient is mandatory; a pathology-based extent of correction leads to a favourable clinical outcome and to a significant reduction in pain. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Age- and severity-adjusted treatment of proximal humerus fractures in children and adolescents-A systematical review and meta-analysis.

BACKGROUND: Fractures of the proximal humerus in patients under the age of 18 years show a low incidence; existing clinical studies only comprise small patient numbers. Different treatment methods are mentioned in the literature but a comparison of the outcome of these methods is rarely made. Up to now, no evidence-based algorithm for conservative and operative treatment is available. The aim of this systematic review with meta-analysis was therefore to gather the best evidence of different treatment methods and their associated functional outcome, complication rates, rates of limb length discrepancies and radiological outcome. METHODS AND FINDINGS: The OVID database was systematically searched on September 30th in 2016 in order to find all published clinical studies on the subject of proximal humerus fractures of patients ≤18 years. Exclusion criteria were previously defined. The Coleman Methodology Score was used to evaluate the quality of the single studies. 886 studies have been identified by the search strategy. 19 studies with a total of 643 children (mean age: 11.8 years) were included into the meta-analysis with a mean Coleman Methodology Score of 71 ± 7.4 points. 18 of the 19 studies eligible for inclusion were retrospective ones, of the best quality available (mean follow-up ≥ 1 year, mean follow-up rate ≥ 65%). 56% of the patients were male. Proximal humerus fractures were treated conservatively in 41% and surgically in 59% of the cases (Elastic Stable Intramedullary Nailing (ESIN): 31%; K-wires: 20%; 8% other methods, e.g. plate osteosynthesis, olecranon traction). The overall success rate (good/excellent outcome) for all treatment methods was 93%. The success rate of ESIN (98%) and of K- wire fixation (95%) was significantly higher (p = 0.01) than the success rate of conservative treatment options (91%). A subgroup analysis of severely displaced fractures (Neer grade III/IV, angulation ≥ 20°) resulted in a change of success rates, to the disadvantage of conservative treatment methods (conservative treatment 82%, ESIN 98%, K-wires 95%; p < 0.001). Complication rates did not differ to a significant extent. 9% of the complications occurred in the patients treated by K-wire fixation, 8% if a conservative treatment option was chosen and 7% in the fractures that were stabilized by ESIN. A change from a one-nail technique to a two-nail technique reduced the complication rate of ESIN significantly. Follow-up X- rays without residual deformity could be found in 96% of the patients treated by ESIN, a rate which was higher than in the patients treated conservatively (93%) or by K-wire fixation (88%). The rate of arm length discrepancies at final follow- up was lower if the fractures were stabilized by ESIN (4%) than if they were treated conservatively (9%) or by K-wires (19%). An evaluation of age-dependent treatment options was performed. CONCLUSIONS: By performing this meta-analysis an evidence-based treatment algorithm could be introduced to treat the fractures according to the severity of displacement and according to the patient's age. For severely displaced fractures ESIN is the method of choice, with the best clinical and radiological outcome.

Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study.

BACKGROUND: To date, prognostic outcome factors for patients undergoing arthroscopic treatment due to chronic patellar tendinopathy (PT) are lacking. The purpose of this study was to investigate whether preoperatively assessed MRI parameters might be of prognostic value for prediction of functional outcome and return to sports in arthroscopic treatment of chronic PT. METHODS: A prospective cohort study was conducted including 30 cases (4 female and 24 male competitive athletes) undergoing arthroscopic patellar release (APR) due to chronic PT. The mean age was 28.2 years (range, 18-49 years) at the time of surgery, and the mean follow-up period was 4.2 years (range, 2.2-10.4 years). Preoperatively assessed MRI parameters included bone marrow edema (BME) of the inferior patellar pole, patellar tendon thickening, infrapatellar fat pad (IFP) edema, and infrapatellar bursitis. Prevalences of preoperative MRI findings were correlated to functional outcome scores in order to determine statistically significant predictors. RESULTS: All athletes regained their preinjury sports levels. Athletes featuring preoperative IFP edema showed significantly inferior modified Blazina score (0.6 ± 0.7 vs. 0.2 ± 0.5), single assessment numeric evaluation (SANE; 86.0 ± 8.8 vs. 94.3 ± 7.5), and Visual Analogue Scale (VAS; 1.0 ± 1.2 vs. 0.3 ± 0.8) compared to subjects without IFP edema (p < 0.05). Return to sports required a mean of 4 ± 3.2 months. On average, patients with IFP edema needed significantly more time to return to sports than subjects without IFP edema (6.5 vs 2.8 months; p < 0.05). The simultaneous presence of BME and IFP edema was associated with significantly inferior outcomes by means of the Victorian Institute of Sport Assessment questionnaire for patients with patellar tendinopathy (VISA-P; 88.1 ± 11.9 vs. 98.6 ± 4.2), SANE (84.3 ± 10.2 vs. 93.1 ± 8.3), and VAS (1.3 ± 1.4 vs. 0.3 ± 0.9) compared to an isolated BME or isolated IFP edema. CONCLUSIONS: This is the first study identifying prognostic outcome factors in arthroscopic treatment of chronic PT. Preoperative IFP edema alone or simultaneous BME and IFP edema on preoperative MRI were associated with inferior functional outcome and delayed return to sports. Knowledge of these predictive factors might improve risk stratification, individualize treatment and postoperative rehabilitation, and contribute to improve clinical outcome. Moreover, current findings offer the potential for novel therapeutic approaches.

Geometry of the Valgus Knee: Contradicting the Dogma of a Femoral-Based Deformity.

BACKGROUND: Realignment osteotomies of valgus knee deformities are usually performed at the distal femur, as valgus alignment is considered to be a femoral-based deformity. This dogma, however, has not been proven in a large patient population. Valgus malalignment may also be caused by a tibial deformity or a combined tibial and femoral deformity. PURPOSE: The purposes of this study were (1) to analyze the coronal geometry of patients with valgus malalignment and identify the location of the underlying deformity and (2) to investigate the proportion of cases that require realignment osteotomy at the tibia, the femur, or both locations to avoid an oblique joint line. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The analysis included 420 standing full-leg radiographs of patients with valgus malalignment (mechanical femorotibial angle [mFTA], ≥4°). A systematic analysis of the coronal leg geometry was performed including the mFTA, mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), and joint-line convergence angle (JLCA). The localization of the deformity was determined according to the malalignment test described by Paley, and patients were assigned to 1 of 4 groups: femoral-based valgus deformity, tibial-based valgus deformity, femoral- and tibial-based valgus deformity, or intra-articular/ligamentary-based valgus deformity. Subsequently, the ideal osteotomy site was identified with the goal of a postoperative change of the joint line of two different maximum values, ±2° and ±4°, from its physiological varus position of 3°. RESULTS: Measurements of the coronal alignment revealed a mean (±SD) mFTA of 7.4° ± 4.3° (range, 4°-28.2°). The mean mLDFA and mean mMPTA were 84.8° ± 2.4° and 90.9° ± 2.6°, respectively. The mean JLCA was 1.2° ± 3.1°. The majority (41.0%) of valgus deformities were tibial based, 23.6% were femoral based, 26.9% were femoral and tibial based, and 8.6% were intra-articular/ligamentary based. To achieve a straight-leg axis and an anatomic postoperative joint line with a tolerance of ±4°, the ideal site of a corrective osteotomy was tibial in 55.2% of cases and femoral in 19.5% of cases. A double-level osteotomy would be necessary in 25.2% of cases. With a tolerance of ±2°, the ideal osteotomy site was the proximal tibia in 41.0% of cases and the distal femur in 13.6% of cases; a double-level osteotomy would be necessary in 45.5% of cases. CONCLUSION: In contrast to the widespread belief that valgus malalignment is usually caused by a femoral deformity, this study found that valgus malalignment was attributable to tibial deformity in the majority of patients. In addition, a combined femoral- and tibial-based deformity was more common than an isolated femoral-based deformity. As a clinical consequence, varus osteotomies to treat lateral compartment osteoarthritis must be performed at the tibial site or as a double-level osteotomy in a relevant number of patients to avoid an oblique joint line.