Objectives

For a long time lateral release (LR) was performed as a standard procedure both, for patellofemoral pain syndrome (PFPS) and patellofemoral instability (PFI). However, recent biomechanical studies have shown that LR is not useful for decreasing the lateral force onto the patella, but is increasing not only medial but also lateral PFI. Furthermore, pain on palpation over the lateral patellofemoral joint space can result in patients treated with extensive LR. We postulate that in case of persistent PFI or PFPS after failed LR the reconstruction of the lateral retinaculum as an addition of the reconstruction of the medial patellofemoral ligament (MPFL) is necessary in terms of decreasing medial PFI as well as lateral pain.

Objective

Overviewing the literature, pain and redislocation after surgical treatment of patellofemoral instability (PFI) is described with up to 30 %, especially with techniques involving the extensor mechanism, the lateral retinaculum or the medial vastus. However, outcome data about revision surgery is missing. Therefore, it was the purpose of this prospective study to evaluate the clinical outcome after revision surgery with an isolated or a combined reco. of the medial patellofemoral ligament (MPFL) with a follow up of 12 months. The indication for additional procedures such as distal femoral osteotomies (DFO), trochleoplasty, reclosing of the lateral retinaculum (RLR) or lateralisation of the tuberosity (LT) were performed depending on the clinical and radiological pathomorphologies.

Focal chondral defects are thought to contribute to the onset of degenerative changes in cartilage and therefore effective treatments of these lesions are aggressively pursued. A number of options such as bone marrow stimulation, osteochondral autograft transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation exist. Long-term data regarding efficacy and outcome for some of these approaches seem to suggest that there is still a need for a low-cost, effective treatment that leads to a sustained improvement in symptoms and the formation of hyaline cartilage.

artilage autologous implantation system (CAIS) is a surgical method in which hyaline cartilage fragments from a non-weight bearing area in the knee joint are collected and then precipitated onto an absorbable filter that is subsequently placed in the focal chondral defect. The clinical outcome of CAIS was compared with microfracture (MFX) in a pilot study. In an IRB approved protocol patients (n=29) were screened with the intention to treat, randomised (2:1, CAIS:MFX) and followed over a 24 month period. To be included in the study the patient may have up to 2 contained focal, unipolar lesions (≤ ICRS grade 3d and ≤ ICRS Grade IVa OCD lesions of femoral condyles and trochlea with a size between 1 and 10 cm². There were no differences in the demographics between the two treatment groups. We report 24 month patient-reported outcome (PRO) data using the KOOS-scale. The values (mean±SD) for the Sport&Recreation (S&R) and Quality of Life scales are shown in the figures below. We noted that at 12 months after the intervention CAIS differentiated itself from MFX in that the changes in S&R were different (p<0.05, t-test) at 12, 18, and 24 months. QoL data were different at 18 and 24 months. The other KOOS-subscales in CAIS and MFX were not significantly different at any time point. The data suggest that CAIS led to an improvement in clinical outcomes in the second year post-intervention. It is possible that the improvement of symptoms that we measured may be associated with the formation of hyaline cartilage. Study funded by ATRM and DePuyMITEK.

Valgus high tibial osteotomy (HTO) results in changes in the frontal as well as sagittal planes. Our hypothesis suggests that patellar height increases and posterior tibial inclination decreases after closed wedge (cw) HTO, whereas patellar height decreases and tibial slope increases after open wedge (ow) HTO.

Lateral radiographs of 100 knees were assessed for patellar height (PH) using Insall-Salvati (ISI), Caton-De Champ (CDI) and Blackburne-Peel indices (BPI) as well as posterior tibial slope. Measurements were done before HTO (50 cw and 50 ow), direct postoperatively and before hardware removal.

In the cw-group all three PH indices increased direct postoperatively and at removal of the hardware with changes in CDI and BPI being significant (P < 0.05). In the ow-group all three indices showed a significant patellar height decrease direct postoperatively and at hardware removal. There were no significant changes between the two follow-up measurements (P > 0.05). Posterior tibial slope showed a significant decrease of 3.1 ± 3.4° after closed wedge HTO and a significant increase of 2.1 ± 3.6° after ow HTO direct postoperatively. In cw-HTO the correlations between frontal plane correction and PH changes were moderate (CDI: r = 0.57; BPI: r = 0.64). In ow-HTO these correlations were weak (CDI: r = 0.44; BPI: r = 0.46). According to ISI there was no correlation (cw: r = 0.11; ow: r =0.16). There was no correlation between PH changes according to CDI and slope changes.

The incidence of patella infera increases after open wedge HTO, whereas the incidence of patella alta increases after closed wedge HTO. We recommend considering the PH and tibial slope before planning for HTO or TKR after HTO, also performing cw-HTO or ow-HTO with the tuberosity left at the proximal tibia in cases of patellofemoral complaint or patella infera.

The Cartilage Autograft Implantation System (CAIS) is being investigated as a potential alternative surgical treatment to provide chondrocyte-based repair in a single procedure for articular cartilage lesion(s) of the knee. CAIS involves preparation and delivery of mechanically morselized, autologous cartilage fragments uniformly dispersed on a 3-dimensional, bio-absorbable scaffold and fixated in the lesion with bio-absorbable staples. CAIS maintains chondrocyte viability and creates increased surface area, which facilitates the outgrowth of embedded chondrocytes onto the scaffold. A proprietary disposable arthroscopic device for harvesting precisely morselized cartilage tissue is used.

In an EU pilot clinical study involving 5 countries 25 patients were randomized and treated using a 2:1 schema of CAIS:microfracture (MFX). Subjects returned for follow-up visits at 1 and 3 weeks and then 2, 3, 6, 9, 12, 18 and 24 months and were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Outcomes at each time point were analyzed with Students t-test.

This study showed that CAIS is safe to use. During the first year, the clinical outcome data in both groups were similar. However, at 18 and 24 months we noted that selected outcome measures were different. At 18 months the Sports & Recreation values were 50.6 ± 22.70 and 21.3 ± 33.25 (p=0.016) for CAIS and MFX respectively and at 24 months 52.1 ± 27.9 and 26.7 ± 26.2 (p=0.061) for CAIS and MFX respectively. At these same time points the Quality of Life data were 43.0 ± 27.14 and 27.2 ± 29.11 (p=0.2) for CAIS and MFX respectively (18 months) and 45.1 ± 28.07 and 20.5 ± 21.47 (p=0.062) for CAIS and MFX respectively (24 months).

While some of the data are not significantly different in this pilot study, taken together they do provide evidence to support the initiation of a more robust clinical trial to investigate efficacy.

The Cartilage Autograft Implantation System (CAIS) is being developed as a potential alternative surgical treatment providing chondrocyte-based repair in a single procedure for articular cartilage lesion(s) of the knee. Two pilot clinical studies were conducted to assess safety and initial performance of the CAIS system.

CAIS involves preparation and delivery of mechanically morselized, autologous cartilage uniformly dispersed on a 3-dimensional, bio-absorbable scaffold, and fixated in the defect with bio-absorbable staples. The mechanical fragmentation of cartilage tissue both maintains viability of the chondrocytes and creates increased surface area, which facilitates the outgrowth of embedded chondrocytes onto the scaffold. A proprietary disposable, arthroscopic device for precisely harvesting viable, morselized cartilage tissue was used. Two pilot clinical studies conducted in the EU and US were designed to assess safety and initial performance of the CAIS. The studies treated 53 patients at 10 enrolling sites, with microfracture as a control. Subjects returned for follow-up visits up to 3 years. Subjects were clinically evaluated and interviewed for the occurrence of adverse events and asked to complete clinical outcome questionnaires, Knee Injury and Osteoarthritis Outcome Score (KOOS), regarding disability, function, pain and quality of life. In addition, MRIs were completed at baseline, 3 weeks, and 6, 12, 24, and 36 months.

The instrumentation enabled the successful preparation and fixation of morselized autologous cartilage tissue loaded implant in a single intraoperative setting. The CAIS device has demonstrated short-term safety in subjects treated to date. Preliminary data from the US pilot study at 12 months and EU pilot study at 6 months indicate that CAIS is safe and its performance based on KOOS clinical outcomes show improvement over baseline and comparability to microfracture. Additional data must be analyzed regarding long-term safety and performance.

In this retrospective study postoperative subscapularis (SSC) function was measured with an electronic force measurement plate (FMP) and clinical scores and correlated with SSC-muscle cross sectional area on defined MRI-sequences.

82 patients with subscapularis tears (34 isolated SSC tears and 48 combined SSC/SSP tears) were followed up at a mean of 38 (24–72) months after tendon reconstruction with the Constant score (CS) and clinical SSC-tests (Napoleon test, Lift off test). SSC-muscle function was assessed in the belly-press- and the lift off position using a custom made electronic FMP (force in Newton). SSC muscle strength values were compared with the contra-lateral side. SSC-muscle atrophy (muscle cross sectional area in mm²) was measured on standardised sagittal MRI-planes and compared with a healthy matched control group (CG) (Mann-Whitney-U-Test).

The mean CS improved from 51p to 81p in isolated tears (group 1) and from an average 47 p to 78 p in combined tears (group 2) (each p< 0.01). Overall 85% of the patients rated their result as good or excellent. Positive and intermediate postop. Napoleon tests were still present in 30% in group 1 and in 25% in group 2. Mean postoperative SSC-muscle strength in the belly-press position averaged 64 N (contralatera sidel-CL: 86 N) in group 1 and 81 N (CL: 91 N) in group 2. Lift-off test strength averaged 36 N (CL: 69 N) in group 1 and 50 N (CL: 63 N) in group 2 (each p< 0.05). Postoperative MRI revealed a significant reduced SSC muscle cross sectional area for the operated side compared with the CG (group 1: SSC: 1974 mm²; CG 2980 mm² p< 0,05; group 2: SSC: 1829 mm²; CG 2406 mm² − SSP: 570 mm²; CG 812 mm² each p< 0,05).

Despite good clinical results after reconstruction of isolated and combined subscapularis tears a marked subscapularis strength deficit remains that is not reflected in the Constant Score, but can be detected with the new measurement device. Additionally a subscapularis muscle atrophy remains in the postoperative course that cannot be reversed by surgery.

Large osteochondral defects of the femoral condyle still pose a difficult problem to treat. A variety of options is available but most of result in replacement with inferior fibrous or hyaline-like cartilage in the load-bearing zone of the knee joint. We present the five year results of Mega-OATS. This technique utilizes the posterior femoral condyle for coverage of osteochondral defects and is called Mega-OATS.

From July 1999, 33 patients of mean age 34.3 years (15–59) were treated with MEGA-OATS. Fifteen patients additionally underwent high tibial osteotomy and two bone grafting using bone harvested from the proximal tibia. The average defect size was 6.2±1.8 cm2. The mean follow up was 66.4±13.2 months. The technique calls for excision of the posterior femoral condyle which is placed in a specially designed work station.

The Lysholm score increased post-operatively from 49.0±19.4 to 88.5±14.9 12 months post surgery to 85.5±16.0 five years post surgery. Three months post-operatively, patients attained a full range of motion and became fully weight-bearing. There was no difference in patients undergoing combined surgery with high tibial osteotomy and patients undergoing Mega OATS as a single procedure after five years. No post-operative meniscal lesions of the posterior horn have been observed.

Mega-OATS achieves a congruent reconstruction of the articular surface in the load bearing zone of the femoral condyle. We consider it a good alternative and salvage procedure in the treatment of large osteochondral defects of the femoral condyle.

The objective of the study was to verify a positive effect of an additional oblique cancellous screw on the primary rotational stability of complete and incomplete high tibial closed-wedge osteotomies (8°) in ovine tibiae. Of 51 specimen 48 were employed for final results. The osteotomy site was stabilized with L-shaped plates (Allopro, Sulzer Orthopedics GmbH, Freiburg, Germany). The specimen were subdivided in 4 groups: complete (1/2) and incomplete (4/5 of the mediolateral tibial diameter in height of the horizontal sawing-jig) (3/4) osteotomies each with (1/3)) and without (2/4) an additional oblique cancellous screw. Constant axial load of 200 Newton and rotational velocity of 0,496°/sec. was applied during testing. 8 ovine specimen were tested without osteotomy or rigid fixation as a control group (5). Statistical significance (p< 0,05) was determined via the nonparametric Mann-Whitney U-test. The results were charted with SPSS (version 11.0). Correlation between objective measurement parameters and primary rotational stability of the specimen was displayed according to Pearson. The primary rotational stabilty in group 1 (intact medial cortical bone, incomplete osteotomy with additional oblique cancellous screw) was significantly higher than in groups 2, 3 and 4. In this group the resulting torsional moments in the initial part of the charted graphs were even higher than in the control group. Group 2 (incomplete osteotomy without a oblique cancellous screw) showed a significantly higher primary rotational stability compared to the groups with complete osteotomy (group 3/4). Between the groups with complete osteotomy (3/4) no significant differences in rotational stability occured. No significant correlation could be found between the objective measurement parameters of the specimen (length, weight, maximal width of the tibial plateau) and the primary rotational stability of the rigidly fixated ovine tibiae. This biomechanical in-vitro assessment showed that an intact medial cortical bone bridge has a statistically significant impact on the primary rotational stability of lateral closed-wedge osteotomies in proximal tibiae. An oblique cancellous screw through the osteotomy gap has an additional effect concerning rotational stability. In case of complete osteotomy of the proximal tibiae or due to inadequate operative technique the stabilizing effect of the medial cortical bone bridge gets lost. This results in a deterioration of rotational stability at the osteotomy site and in a sufficicantly rigid fixation is no longer guaranteed. In this case an additionally inserted oblique cancellous bone screw leads to higher resistance against rotational forces. A rigid osteosynthetic stabilization of corrective osteotomies in proximal tibiae seems a condition precedent to obtain the desired correction angle.

The fluorescent microsphere (FM) method is considered the best technique to determine regional bone blood flow (RBBF) in acute experiments. In this study we verified the accuracy and validitiy of this technique for measurement of RBBF in a long-term experiment and examined RBBF after meniscectomy. 24 anesthetized female New Zealand rabbits (3 groups, each n=8) received consecutive left ventricular injections of FM in defined time intervals after meniscectomy. Group 1 from preoperatively to 3 wks postoperatively, group 2 from 3 wks to 7 wks, and group 3 from 7 wks to 11 wks postoperatively. To test the precision of the FM-method in long-term experiments two FM-species were injected simultaneously at the first and last measurement. After the experiment both humeri, femora, and tibiae and reference organs (kidney, lung, brain) were removed and dissected according to standardized protocol. Fluorescence was determined in each reference blood and tissue sample and blood flow values were calculated. Blood flow in kidney, lung, and brain revealed no significant difference between right and left side and remained unchanged during the observation period excluding errors due to shunting and dislodging of spheres in our experiments. Comparison of relative bone blood flow values obtained by simultaneously injected FM showed an excellent correlation at the first and last injection indicating valid RBBF measurements in long-term experiment. We found a significant increase of RBBF 3 wks after meniscectomy in the right tibial condyles compared to the non-operated left side. Similar changes were found in the femoral condyles. RBBF in other regions of tibia, femur, and humerus revealed no significant difference between right and left bone samples of the same region. Our results demonstrate that the FM method is also valid for measuring regional bone blood flow in long-term experiments. In addition we could demonstrate that meniscectomy leads to an increase of RBBF in the tibial condyles very early. This increase might be caused by stress-induced alterations of the subchondral bone.

Introduction and Aims: The possible deleterious effects of long distance running remain controversial. The repetitive loading could potentially predispose to the subsequent development of osteoarthritis. The purpose of this study is to investigate whether external impact loading in marathon runners creates internal stresses on bone and cartilage that are demonstrable on MR images.

Method: Six recreational, two semi-professional runners and seven beginners underwent magnetic resonance (MR) imaging of the hip and knee before and after a marathon run using coronal body phased-arrayed coil and the following pulse sequences: a coronal T1 weighted spin echo sequence and STIR sequences. To be included in the study, the runners had to successfully finish a previous race in less than 4.5 hours. The following exclusion included surgery for overuse injuries in the prior 48 months, and symptoms of overuse in the six months preceding the race.

Results: The pre- and post-run scans failed to demonstrate marrow oedema, periosteal stress reactions or joint effusions in seven runners. One patient who underwent a reconstruction of his anterior cruciate ligament 18 months ago demonstrated a small effusion in the reconstructed knee before and after the race. Six of the beginners demonstrated minimal effusions in the hip and knee joints. However no bone oedema was seen in any of the beginners.

Conclusions: Our results suggest that the high impact forces in long distance running are well tolerated and subsequently not demonstrated on MR images in experienced runners. Beginners do compensate the impact stresses to a certain extend and it is postulated that long distance runners undergo a natural selection process.

High tibial osteotomies are commonly performed for varus/valgus malalignment of the knee. In the past we have been well aware that a high tibial osteotomy corrects the coronal plane but we did not consider changes of the tibial slope. Altering the slope has an impact on the in situ forces of the cruciate ligaments and influences the stability of the knee. The purpose of this study was to investigate the amount of alteration of the tibial slope by a closed wedge osteotomy.

From January 2001 to September 2001 we reviewed retrospectively all Xrays of patients that underwent a high tibial osteotomy or were admitted for removal of hardware. 80 patients were included. 67 patients could be followed up.

The slope on the preoperative xrays was 6,1 degrees (0–12). A closed wedge osteotomy decreased the slope by a mean of 4,88 degrees. A high tibial osteotomy of six degrees in the coronal plane decreased the slope by 4.29 degrees, a HTO of eight degrees decreased the slope by 7 degrees, a HTO of ten degrees by altered the slope by 4.75 and of twelve degrees by decreased the slope by 6.5 degrees.

A closed wedge osteotomy decreases the tibial slope. It is the preferred technique when a combined procedure (HTO and ACL reconstruction) is planned. There is no correlation between the degree of correction of the coronal plane by a closed wedge high tibial osteotomy and changes of the tibial slope.

Osteochondral autologous transplantation (OATS) is a new technique for the treatment of osteochondral defects.

In a prospective study between April 1996 und May 2001 we used the OATS technique to treat 201 patients (125 male, 76 female) with a mean osteochondral defect of 3,3 cm². The defect was in the medial femoral condyle in 96 cases, the lateral femoral condyle in 16, the patella in 22, the trochlea in seven, the tibial plateau in one, the talus in 48, the tibial plafond in two and capitellum in four. There were 17 other locations. The procedure was performed either open or arthroscopically. A mean of 2,2 cylinders was transplanted.

The Lysholm score in the lower limbs increased from a preoperative mean of 58,3 (20 to77) to a mean of 90,2 (70 to 100). Treatment by OATS alone increased the score from 65,2 to 91,6. With additional ACL/PCL reconstruction, the score increased from 49,9 to 82,6. The combination of OATS, HTO, ACL/PCL reconstruction increased the Lysholm score from 55,5 to 85,5. Ten per cent of patients complained of pain at the donor site in the lateral femoral condyle. There were no complications related to OATS performed in the upper limbs, and control MRI three months postoperatively showed incorporation of all cylinders.

The results are encouraging, and give rise, to the hope that this cost-effective and safe treatment for limited osteochondral defects may delay or even prevent the onset of osteoarthritis.

Posttraumatic shoulder instability is a common problem in the field of sports medicine. Especially overhead athletes need intact stabilisers to meet the functional requirements. Open procedures often result in limitations of movement postoperatively. Arthroscopic techniques offer potential advantages such as better range of motion and shorter rehabilitation times.

Between September 1996 and October 2000 159 arthroscopic shoulder stabilisations were performed with FASTak® anchors. The mean follow up was 24.9 months (12–50). Rowe score and a visual analogue scale were used to measure patient satisfaction. 72 patients (m=57, f=15)with a mean age of 27.6 years (17–65) were included and clinically examined.

The Rowe score increased to 83.1 after primary stabilisation and 68.1 after revision procedures. The visual analogue score demonstrated overall patient satisfaction. 89.1% (n=64) of the patients could return to sports with 68,4% (n=49) being able to return to their previous sports activity level. Overhead athletes returned to sports in 89.4% of cases and 63.3% to their pre-injury level. In the non-overhead athletes 86% returned to sports with 60% to their pre-injury level.

This study demonstrates that arthroscopic shoulder stabilisation with FASTak® anchors may be offered to the athlete regardless of the sports activity. It allows return to sports in a high percentage and does offer the potential advantages of a faster return to the previous activity level, better range of motion and less postoperative pain. Disadvantages of the technique is a long learning curve and should therefore only be performed by dedicated and experienced shoulder surgeons.

Introduction Osteochondral autologous transplantation (OATS) is a technique to treat hyaline cartilage injuries in different joints. It delivers high quality hyaline cartilage to the defect.

Methods In a prospective study we used the OATS technique in 201 patients (125 male, 76 female). The mean defect size was 3.3 sq cm. The medial femoral condyle was treated in 96 cases, the lateral femoral condyle in 16, the patella in 22, the trochlea in seven, the tibial plateau in one, the talus in 48, the tibial plafond in two and the capitellum in four. There were 17 other locations. The procedure was performed either open or arthroscopically. A mean of 2.2 cylinders were implanted. Mal-alignment was corrected in 20 cases with an osteotomy and instability of the knee by anterior (ACL) or posterior (PCL) reconstruction. Five patients required reconstruction of both the ACL and PCL.

Results The Lysholm score increased from 58.3 (20 to 77) to a mean of 90.2 (70 to 100) in the lower extremity. Treatment by OATS alone increased the score from 65.2 to 91.6. With additional ACL/PCL reconstruction, the score increased from 49.9 to 82.6. The combination of OATS, HTO and ACL/PCL reconstruction increased the Lysholm score from 55.5 to 85.5. Post-operative MR imaging with intravenous contrast showed incorporation of all but one cylinder. Complications included one case of arthrofibrosis and sinking of one cylinder. One patient developed regional pain syndrome and three had pain at the malleolar osteotomy site resolved by screw removal. Ten percent of the patients developed pain at the donor site.

Conclusions The results are encouraging. It is a cost effective and safe treatment.

Introduction High tibial osteotomies (HTO) are commonly performed for either varus or valgus malalignment of the knee. In the past we have been well aware that HTO corrects the coronal plane of the knee, but we did not consider changes of the tibial slope in the sagittal plane when planning or evaluating osteotomies. Because the tibia is a three-dimensional structure with a triangular shape, osteotomy may result in changes in both the coronal plane and the sagittal plane. Altering the tibial slope has an impact on the in situ forces of the cruciate ligaments and may influence the stability of the knee. The purpose of this study is to investigate any possible alteration of the tibial slope introduced by HTO.

Methods This study was conducted as a retrospective radiographic review of a consecutive series of patients. Between January and September 2001 a total of 80 patients underwent either HTO or the removal of hardware from a prior HTO. The radiographs of 67 of these patients were suitable for review. There were 41 males with an average age of 36.6 years (17 to 67). There were 26 females with an average age of 39.4 years (19 to 62). Routine radiographs of the knee were obtained using standard methods, and these were assessed by comparison to corresponding preoperative studies.

Results The posterior slope on pre-operative radiographs averaged 6.1° (0 to 12). HTO using a closing wedge technique was found to decrease this posterior slope by a mean of 4.9°. The change in the posterior slope was not found to correlate directly with the magnitude of the correction in the coronal plane. HTO of six degrees in the coronal plane decreased the posterior slope by 4.3° degrees, HTO of eight degrees decreased the posterior slope by seven degrees, HTO of 10° altered the slope by 4.8° degrees, and HTO of 12° degrees decreased the posterior slope by 6.5°.

Conclusions HTO by a closing wedge technique for sagittal plane correction often distorts alignment in the coronal plane as well, resulting in a decrease in the normal posterior tibial slope. We found no direct correlation between the degree of correction of the coronal plane and alteration of the tibial slope. Decreasing this slope potentially decreases in situ forces acting on the ACL while simultaneously increasing forces acting on the PCL. This may have advantages when managing combined cases with both malalignment and instability. The closing wedge technique is our preferred method when a combined procedure (HTO and ACL reconstruction) is planned.

In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits.

Introduction Traumatic shoulder dislocations at a young age result in a significant re-dislocation rates and lead to chronic instability. Conservative treatment fails in 25% to 96% of cases especially in young active patients. The accepted standard treatment is the classical open Bankart repair. Re-dislocation rate could be decreased to 3.5% to 14.9% but almost always results in loss of motion. The development of new techniques and devices has lead to an increase in arthroscopic techniques for shoulder stabilisations.

Methods Between September 1996 and October 2000, 262 arthroscopic shoulder stabilisations were performed by one surgeon (ABI). For the refixation of the injured labrum suture anchors were used. In 159 cases FASTak (Arthrex) titanium anchors, in 26 cases Panalok (Mitek) and in 57 cases Suretac (Smith and Nephew) were used. The minimum follow-up was 12 months with a mean follow-up of 24.9 months (12 to 50). Exclusion criteria were SLAP and HAGL lesions, glenoid fractures, the inverted pear sign and hooked or posterior dislocations. Rowe score and a visual analogue scale were used to measure patient satisfaction.

Results The Rowe score increased to 83.1 +/− 20.9. The visual analogoue score demonstrated overall patient satisfaction. The redislocation rate was five percent, three percent having a history of adequate trauma. Complaints of subluxations and ongoing instability occured in six percent. Eighty-nine percent of the patients could return to sports with 68% being able to return to their previous sports level.

Conclusions This study demonstrates that arthroscopic shoulder stabilisation is comparable to the golden standard of open Bankart repair.

Aim: CMI was designed to support regeneration of the meniscus and to improve symptoms in patients after meniscectomy. We use CMI for meniscal replacement in patients with multiple knee problems in combination with other reconstructive procedures. Methods: Eleven patients (4f, 7m), average age 36 years (24–56 y.), were included in the prospective evaluation with minimum follow-up of 12 months (mean 24.5 mo, range 13–38 mo). Ten patients had previous surgeries (9 meniscectomies, 4 ACL reconstructions). CMI transplantation was performed in combination with HTO (n=6), ACL reconstruction (n=4) and autologous osteochondral transplantation (OATS) (n=6). Additional to a clinical evaluation, 6 patients underwent a diagnostic arthroscopy and biopsy. Results: Pain scores reduced from 5.4±1.3 to 2.3±0.7 (VAS 1=no pain, 10=worst pain). The knee function was evaluated B (nearly normal) in all patients. Lysholm score increased from 70 to 94 in patients with CMI/HTO, respectively 58 to 91 in patients with CMI/ACL and 71 to 93 in patients with CMI/OATS. Arthroscopic views demonstrated good integration and intact CMI implants especially in the middle and anterior parts of the menisci. Histological findings showed interstitial spaces of the matrix filled with fibrous matrix and oval cells resembling fibrochondrocytes in some regions. Conclusions: The results of arthroscopy, histology and the good clinical outcome support our treatment philosophy addressing all knee pathologies at once. CMI can be included in combined knee procedures, since the integration and generation of a new meniscus are improved with re-established articular surface and knee alignment.

Large osteochondral defects are difficult to treat, but several treatment options are available. The posterior condyle transfer salvage technique described by Wagner in 1964 and Imhoff in 1990 has been developed further and is now used for coverage of large osteochondral defects in the load-bearing zone. The new technique is called MEGA-OATS.

From July 1999, 25 patients of mean age 33.3 years (17 to 60) were treated with MEGA-OATS. Thirteen patients additionally underwent high tibial osteotomy and two bone grafting, using bone harvested from the proximal tibia. The mean follow up was 17.8 months. The technique calls for excision of the posterior femoral condyle which is placed in a specially designed work station. A MEGA-OATS cylinder of diameter 20 mm to 35 mm is prepared and, using the press-fit technique, grafted into the prepared defect zone. The Lysholm score increased postoperatively from 66.33 (49 to 71) to 87.8 (72 to 97). Three months postoperatively control MRI showed incorporation of all cylinders. Between six and 12 weeks postoperatively patients attained a full range of motion and became fully weight-bearing. To date one superficial infection resolving on oral antibiotics and two cases of arthrofibrosis four months postoperatively that required arthroscopic release were seen. No postoperative meniscal lesions of the posterior horn have been observed.

MEGA-OATS achieves a congruent reconstruction of the articular surface in the load-bearing zone of the femoral condyle. We consider it a good alternative in the treatment of large osteochondral defects of the femoral condyle in young patients.

It is suggested that there is a link between arch type of the foot and overuse injuries. The use of individual selected running shoes can reduce running injuries substantially. To select the correct shoe the runner needs to have appropriate knowledge of his own foot anatomy and biomechanics. A questionnaire was used to investigate the knowledge of the runner about his arch height and biomechanics of running. Clinical examination was performed by 5 orthopaedic surgeons and experienced orthopaedic technicians. Weight-bearing podograms were used to further define the deformity.

We examined 92 volunteers with a mean age of 35.4 (12–63) years, a mean size of 176 cm (154–195) with a mean body weight of 70.38 kg (45–95). Eighteen out of 47 runners with a flatfoot deformity identified their deformity correctly. Twenty five out of 43 volunteers with a normal arch were correct in assessing their foot. Two runners with a cavus foot were correct in identifying their foot. Only 4 out of 38 runners that diagnosed themselves as being pronators have been found to be pronators. Four runners with a self-diagnosed non-pro-nating foot were classified as being pronators. Three runners that could not classify themselves were diagnosed as pronators.

This study demonstrates the poor knowledge of foot deformities in the running community.

High tibial osteotomy is commonly performed for varus/ valgus misalignment of the knee. Altering the sagittal plane can affect the forces of the cruciate ligaments and influence stability. This retrospective study looked at the alteration of the tibial slope produced by closed wedge osteotomy, in which the importance of the sagittal plane is often overlooked.

We followed-up 67 of 80 patients admitted for high tibial osteotomy or removal of hardware between January and September 2001. The mean age of the 41 men was 36.6 years (17 to 67) and of the 26 women 39.4 years (19 to 62).

On preoperative radiographs the mean slope was 6.1( (0( to 12(). The frontal plane was changed by a mean of 7.93( (2( to 12(). A closed wedge osteotomy decreased the slope by a mean of 4.88( (0( to 10( posteriorly and 0( to 6( anteriorly). Alteration of the coronal plane by 6( decreased the slope by 4.29(, 8( by 7(, 10( by 4.75( and 12( degrees by 6.5(.

A closed wedge osteotomy decreases the tibial slope. This causes an anterior shift in the starting position of the tibia, potentially decreasing in situ forces acting on the anterior cruciate ligament. There was no correlation between the correction of the coronal plane and alteration of the sagittal plane.

It is suggested that there is a link between overuse injuries and the type of arch of the foot, and that the use of appropriate running shoes may reduce running injuries substantially. However, to select the correct shoe, a runner needs knowledge of the anatomy and biomechanics of his/her foot.

Five orthopaedic surgeons and experienced orthopaedic technicians examined the feet of 92 runners of mean age 35.4 years (12 to 63), mean height 176 cm (154 to 195) and mean body weight 70.38 kg (45 to 95). Weight-bearing podograms were used to define deformities of the feet further. A questionnaire ascertained what runners knew about their arch heights and the biomechanics of running. Of 43 volunteers with normal arches, 25 correctly assessed their feet, but only 18 of 47 runners with a flatfoot deformity identified their deformity. Two runners with a cavus foot identified it correctly. Only four of 38 runners who diagnosed themselves as pronators were found to be, and four runners who self-diagnosed non-pronation were classified as pronators. Three runners who could not classify themselves were diagnosed as pronators.

This study demonstrates the poor knowledge of foot deformities in the running community.

Osteochondral autologous transplantation (OATS) is a new technique for the treatment of osteochondral defects.

In a prospective randomised study, between November 1996 and June 2000 we used the OATS technique to treat 136 patients (90 male, 46 female) with a mean osteochondral defect of 3.3 cm2. The defect was in the medial femoral condyle in 54 cases, the lateral femoral condyle in nine, the patella in 15, the trochlea in six, the tibial plateau in one, the talus in 29, the tibial plafond in two, the capitellum in four. There were 16 other locations. The procedure was performed either open or arthroscopically. A mean of 2.2 cylinders was transplanted. At the same time, we treated malalignment by high tibial osteotomy (HTO) in 20 patients, and instability by anterior (ACL) or posterior cruciate ligament (PCL) reconstruction in 16. Five patients required reconstruction of both ACL and PCL.

The Lysholm score in the lower limbs increased from a preoperative mean of 58.3 (20 to 77) to a mean of 90.2 (70 to 100). Treatment by OATS alone increased the score from 62.9 to 91.6. The combination of OATS and HTO increased the score from 65.2 to 91.6. With additional ACL/PCL reconstruction, the score increased from 49.9 to 82.6. The combination of OATS, HTO and ACL/PCL reconstruction increased the Lysholm score from 55.5 to 85.5. Control postoperative MRI with IV contrast (Gd-DTPA) showed incorporation of all but one cylinder. Complications included one case of arthrofibrosis and sinking of one cylinder. One patient developed regional pain syndrome and three had pain at the malleolar osteotomy site, resolved by screw removal. For four weeks after the operation, 10% of patients complained of pain at the donor side in the lateral femoral condyle. There were no complications related to OATS performed in the upper limbs, and control MRI three months postoperatively showed incorporation of all cylinders.

The results are encouraging, and give rise to the hope that this cost-effective and safe new treatment for limited osteochondral defects may delay or even prevent the onset of osteoarthritis.

Knee trauma often causes meniscal injuries. Only 15% of all tears can be repaired. Partial or complete meniscectomy subsequently leads to an increased incidence of chondral damage and onset of early osteoarthritis. In Europe in 1999, 355 000 meniscal injuries were treated, 284 000 of which required partial or complete meniscectomy

As an alternative to allograft, the collagen meniscus implant (CMI®) can be used for reconstruction. A collagen matrix moulded in the form of a meniscus, this is trimmed to defect size and sutured into place arthroscopically. It then serves as a scaffold for cellular invasion. Indications are tears that require partial meniscectomy or an intact remnant stable meniscus. Cruciate ligament injuries, malalignment, osteoarthritis and stage-IV osteochondral defects are the principal contraindications.

Between July 1998 and March 2000, 10 patients received a CMI in our department. Additional pathologies (four anterior cruciate ligament (ACL) injuries, four varus malalignments and five chondral defects) were treated simultaneously. The Lysholm score increased from 70 to 99 in patients treated with an additional high tibial osteotomy (HTO), from 58 to 91 in the group with ACL reconstruction, from 71 to 93 in patients with osteochondral autologous transplantation (OATS). The Lysholm score of the combined group (two patients with HTO and OATS, two with HTO and ACL reconstruction) improved from a preoperative 69 to 99 postoperatively.

CMI, a biocompatible resorbable implant, induces cellular ingrowth and arthroscopic implantation. However, there are still questions to be answered. Few cases have been reported and no long-term studies have yet been published. It is not yet known whether osteochondral defects, unstable joints or malignment are limitations of using the implants.

Large osteochondral defects are difficult to treat, but several treatment options are available. The posterior condyle transfer salvage technique described by Wagner in 1964 and Imhoff in 1990 has been developed further, and is now used for coverage of large osteochondral defects in the load-bearing zone. The new technique is called MEGA-OATS.

From July 1999, 17 patients of mean age 39 years (16 to 6) were treated by MEGA-OATS. Two patients additionally underwent high tibial osteotomy and two bone grafting, using bone harvested from the proximal tibia. The mean follow-up was 12 months. The technique calls for excision of the posterior femoral condyle, which is placed in a specially designed work station. A MEGA-OATS cylinder of diameter 20 mm to 35 mm is prepared and, using the press-fit technique, grafted into the prepared defect zone.

The Lysholm score increased postoperatively from 63 (49 to 71) to 81 (72 to 85). Three months postoperatively control MRI showed incorporation of all cylinders. Between six and 12 weeks postoperatively, patients attained a full range of motion and became fully weight-bearing. To date no postoperative complications or meniscal lesions of the posterior horn have been observed.

MEGA-OATS achieves a congruent reconstruction of the articular surface in the load-bearing zone of the femoral condyle. We consider it a good alternative in the treatment of large osteochondral defects of the femoral condyle in young patients.