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Petersen W, Mustafa HA, Buitenhuis J, Braun K, Häner M. [Reconstruction of the medial collateral ligament complex with a flat semitendinosus auto- or allograft]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2024:10.1007/s00064-024-00856-8. [PMID: 39172277 DOI: 10.1007/s00064-024-00856-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/27/2023] [Accepted: 08/28/2023] [Indexed: 08/23/2024]
Abstract
OBJECTIVE Replacement of superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with an allograft. INDICATIONS Chronic 3° isolated medial instability and combined anteromedial or posteromedial instability. CONTRAINDICATIONS Infection, open growth plates, restricted range of motion (less than E/F 0-0-90°). SURGICAL TECHNIQUE Longitudinal incision from medial epicondyle to superficial pes anserinus and exposure of the medial collateral ligament complex. Thawing of the allogeneic semitendinosus tendon graft at room temperature, reinforcement of the tendon ends with sutures and preparation of a two-stranded graft. Placement of guidewires in the sMCL and POL insertions and control with image intensifier. Tunnel drilling. Pulling the graft loop into the femoral bone tunnel and fixation with a flip button. Pulling the two graft ends into the tibial tunnels. Tibial fixation by knotting the suture ends in a 20° flexion on the lateral cortex. Suture the tendon bundles to the remaining remnants of the medial collateral ligament complex to adopt the flat structure of the natural medial collateral ligament complex. POSTOPERATIVE MANAGEMENT Six weeks partial weight-bearing, immediately postoperatively splint in the extended position, after 2 weeks movable knee brace for another 4-6 weeks. Mobility: 4 weeks 0-0-60, 5th and 6th weeks 0-0-90. RESULTS From 2015-2021, this surgical procedure was performed in 19 patients (5 women, 14 men, age 34 years). Mean Lysholm score at follow-up after at least 2 years was 89 (76-99) points. In 6 patients, there was restricted range of motion 3 months postoperatively, which resulted in further therapy (3 × systemic cortisone therapy, 3 × arthroscopically supported manipulations under anesthesia).
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Affiliation(s)
- Wolf Petersen
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland.
| | - Hassan Al Mustafa
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Johannes Buitenhuis
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Karl Braun
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Martin Häner
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
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Krutsch W, Kobes T, Huber L, Szymski D, Geßlein M, Rüther J, Alt V, Weber J. [Complex knee injuries in football : Management from injury to return to competition]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:438-448. [PMID: 38801525 DOI: 10.1007/s00132-024-04508-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Knee joint injuries are a regular and serious injury in football, often resulting in a long period of absence for players and are, therefore, a significant disadvantage for clubs. The various structures of the knee joint, such as ligaments, meniscus or cartilage, are exposed to the risk of injury due to different sport-specific situations in football and require different and specific therapeutic approaches for their adequate healing. TREATMENT Both surgical and conservative treatment measures have been well investigated scientifically, especially for knee joint injuries in football, so that a successful and sustainable return to play on field is highly possible. Only in professional football is there a deviation from the usual standard of treatment in special situations in order to meet the demands and goals of professional footballers. In order to do address different subpopulations in football in the various injury types, both in treatment and in the return to play decision and, thus, sustainable secondary prevention, in addition to knowledge of scientific evidence on knee joint injuries, basic experience in the sport in which the patients with knee joint injuries are active is also useful.
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Affiliation(s)
- Werner Krutsch
- SportDocsFranken, Zentrum für Kniechirurgie, Elisabeth-Selbert-Platz 1, 90473, Nürnberg, Deutschland.
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland.
| | - Thomas Kobes
- SportDocsFranken, Zentrum für Kniechirurgie, Elisabeth-Selbert-Platz 1, 90473, Nürnberg, Deutschland
| | - Lorenz Huber
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
| | - Dominik Szymski
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
| | - Markus Geßlein
- Klinik für Orthopädie und Unfallchirurgie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Nürnberg, Deutschland
| | - Johannes Rüther
- Klinik für Orthopädie und Unfallchirurgie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Nürnberg, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
| | - Johannes Weber
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland
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Häner M, Petersen W. [Treatment of acute injury of the anterior cruciate ligament : Always only reconstruction?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:8-17. [PMID: 37597054 DOI: 10.1007/s00113-023-01357-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/21/2023]
Abstract
The aim of treatment of a ruptured anterior cruciate ligament (ACL) is the return of the patient to an acceptable level of activity without giving way phenomena as well as adequate treatment of prognostically relevant concomitant lesions. The treatment of acute ACL ruptures can be either early reconstruction or a primary physiotherapy with optional later reconstruction. Which path is taken depends on possible concomitant injuries that require early surgical intervention (e.g., repairable meniscal injury or distal rupture of the medial collateral ligament) and on patient-specific factors (age, level of activity). Isolated ruptures of the ACL can also be primarily treated without surgery. Then the injured knee joint should first be so far conditioned by rehabilitative measures that pain, swelling and posttraumatic restriction of movement are improved and neuromuscular training can be started. A screening test consisting of jumping tests, patient-reported outcome measures and the testing for giving way phenomena can be suitable to differentiate compensators (copers) from noncompensators (non-copers). Surgical reconstruction of the ACL should be recommended to non-compensators in the sense of participatory decision-making. Activity modification (adapter) can also be considered as a treatment strategy. If instability events (giving way) or secondary meniscal lesions occur during nonsurgical therapy, cruciate ligament reconstruction should be considered.
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Affiliation(s)
- Martin Häner
- Sportklinik Berlin und Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar-Theyß-Str. 27-31, 14193, Berlin, Deutschland
| | - Wolf Petersen
- Sportklinik Berlin und Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar-Theyß-Str. 27-31, 14193, Berlin, Deutschland.
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Takahashi T, Takeshita K. In Vivo biomechanical evaluations of suture anchors for repairing grade 3 superficial medial collateral ligament injury in a porcine model. J Orthop Surg (Hong Kong) 2021; 29:23094990211021536. [PMID: 34121508 DOI: 10.1177/23094990211021536] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To clarify the biomechanical and radiological outcomes of superficial medial collateral ligament (sMCL) repair using suture anchors in a large animal model. METHODS The right sMCLs of nine male castrated pigs was completely detached at the femoral attachment. sMCL repair surgery was performed using two suture anchors. The same skin incision, sMCL exposure, and immediate wound closure were made at the left knee as a sham surgery. Magnetic resonance imaging was performed preoperatively and 4 weeks after surgery. The structural properties (upper yield load, maximum load, linear stiffness, and elongation at failure) of the femur-sMCL-tibia complex were determined. RESULTS During tensile testing, all the repaired sMCLs avulsed from the femoral attachment. There were no significant differences in the upper yield load, maximum load, linear stiffness, or elongation at failure between the groups 4 weeks after surgery or in the MRI-derived signal-to-noise quotients (SNQs) at the mid and tibial sMCL. The SNQs differed significantly at the femoral (2.7 ± 1.2 vs 0.3 ± 0.7; P = 0.00064) portions between groups. CONCLUSION The injured sMCLs biomechanically recovered after surgery using suture anchors even though the SNQs were higher than those with native contralateral sMCLs. For clinical relevance, sMCL repair of grade 3 sMCL injuries using suture anchors was both safe and successful with less tissue dissection.
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Affiliation(s)
- Tsuneari Takahashi
- Department of Orthopaedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
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Petersen W, Bierke S, Karpinski K, Häner M. [Arthroscopic meniscus transplantation without bone blocks]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:546-555. [PMID: 34519837 DOI: 10.1007/s00064-021-00731-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/21/2021] [Accepted: 03/29/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Replacement of the lateral or medial meniscus with an allogeneic graft. INDICATIONS Complete loss of inner or outer meniscus. CONTRAINDICATIONS Grade 3 to 4 cartilage damage in the corresponding compartment, uncorrected varus or valgus deformities > 5°, symptomatic instabilities. SURGICAL TECHNIQUE Knee joint arthroscopy via the high anterolateral standard portal and checking the indication. Thaw the allogeneic meniscus graft in NaCl at room temperature and incubate in vancomycin solution. Refreshment of the capsule and resection of remnants of the meniscus. Search for the insertion zones on the tibial plateau, debridement, insert a transtibial targeting device and drill target wires in the middle of the insertion zones. Overdrill the target wires with a 4.5 mm drill. Short medial or lateral arthrotomy (approx. 2 cm). Reinforcement of the anterior and posterior horns of the meniscus graft with nonresorbable suture material (e.g. "fiber wire" size 5). Insertion of K‑wires with thread loops into the tibial bone tunnel. The reinforcement threads of the meniscus transplant are drawn into the bone tunnel via the thread loops, and the meniscus transplant is drawn into the joint. Reduction of the meniscus base to the capsule and refixation of the meniscus to the capsule with "inside out" or "all inside" sutures. POSTOPERATIVE MANAGEMENT Six weeks partial weight-bearing using a hinged brace, then gradually increased load. Range of motion: 4 weeks 0‑0-60°, then 2 weeks 0‑0-90°, followed by no restrictions. RESULTS In our hospital, 15 patients (6 × medial, 9 × lateral) were treated using the described surgical technique. After a minimum period of 1 year (mean = 14.2 months), meniscus extrusion-measured in the MRI-averaged 2.7 mm. The Lysholm score rose from an average of 70.2 (±7.4) to 90.1 points (±10.6). In one case, due to an early reruption, revision with renewed meniscus refixation had to be performed 10 days after the operation. In another case, meniscus resection was performed 6 months after the meniscus transplant due to a reruption. Thrombosis, infection and arthrofibrosis were not observed.
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Affiliation(s)
- Wolf Petersen
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus Berlin, Caspar-Theyß-Straße 27-31, 14193, Berlin, Deutschland.
| | - Sebastian Bierke
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus Berlin, Caspar-Theyß-Straße 27-31, 14193, Berlin, Deutschland
| | - Katrin Karpinski
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus Berlin, Caspar-Theyß-Straße 27-31, 14193, Berlin, Deutschland
| | - Martin Häner
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus Berlin, Caspar-Theyß-Straße 27-31, 14193, Berlin, Deutschland
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Otto A, Helal A, Imhoff FB, Mehl J, Herbst E, Achtnich AE, Forkel P, Imhoff AB, Schmitt A. Promising clinical and magnetic resonance imaging results after internal bracing of acute posterior cruciate ligament lesions in multiple injured knees. Knee Surg Sports Traumatol Arthrosc 2020; 28:2543-2550. [PMID: 32047998 DOI: 10.1007/s00167-020-05852-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 01/10/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical and radiological outcomes of acute posterior cruciate ligament (PCL) lesions in multiple injured knees that were surgically treated with internal bracing. METHODS Acute complete PCL lesions in multiple injured knees with subsequent internal-bracing treatment within 21 days between 2014 and 2016 were eligible for inclusion. At final follow-up, patients were assessed with Tegner, Lysholm, and IKDC scores. PCL stability and healing were verified with KT-2000, stress radiography and magnetic resonance imaging (MRI). RESULTS Fourteen patients [mean age 37.4 (± 17.8; SD) years] were evaluated after a mean follow-up of 19.9 (± 7.7; SD) months. Thirteen patients suffered complete lesions of the PCL with concomitant ligamentous injuries (Schenck I: six cases, Schenck III M: five cases, Schenck IV N: one case, Schenck V: one case). Median Tegner, mean Lysholm and mean IKDC scores at follow-up were 4 (2-7; interquartile range), 69.1 (± 16.6; SD) and 68.9 (± 18.1; SD) respectively. Posterior translation averaged 5.8 (± 2.2; SD) mm with the KT 2000 and stress radiography showed a mean posterior tibial translation of 5.5 (± 4.1; SD) mm in the side to side comparison. MRI showed adequate PCL healing. CONCLUSIONS Internal bracing as treatment for acute PCL ruptures in multiple injured knees showed adequate restoration of posterior tibial translation in a single-centre study including 14 cases. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alexander Otto
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Augsburg, Germany.
| | - Ahmed Helal
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julian Mehl
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Elmar Herbst
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andrea E Achtnich
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philipp Forkel
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Schmitt
- Department of Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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Petersen W, Karpinski K, Bierke S, Hees T, Häner M. [Primary revision with replasty of the anterior cruciate ligament]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:221-247. [PMID: 31172213 DOI: 10.1007/s00064-019-0606-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Restoration of knee stability after rerupture of an anterior cruciate ligament (ACL) graft. INDICATION Acute and chronic functional instability with rerupture of an ACL graft with subjective instability with anatomical or non-anatomical bone tunnel without tunnel widening. CONTRAINDICATIONS Partial anatomical bone tunnels of the previous operation, significant tunnel widening of anatomical bone tunnels, local infection of the knee joint, local soft tissue damage. SURGICAL TECHNIQUE Graft choices are hamstring tendons (semitendinosus muscle, gracilis muscle), the quadriceps tendon, patellar tendon and a peroneus tendon split graft. In cases with anatomical tunnels, careful debridement is performed down to the tunnel wall. In non-anatomical tunnels, a new femoral tunnel is drilled over a deep anteromedial portal with the knee flexed more than 110° in the insertion area of the ACL. Using drills and dilators, a tunnel is prepared. At the tibia, the anterior horn of the lateral meniscus serves as a landmark in the absence of an ACL stump. The cortical tibial tunnel aperture is probed with a guide wire and the tunnel is drilled stepwise until the tunnel wall is reached, which is debrided with a spoon or synovial resector to remove graft residues and implants from the tunnel. The femoral fixation can either be done with a flip button, an interference screw or in the case of a bone block graft implant-free. At the tibial side, the graft is fixed with a resorbable interference screw and fixation button. POSTOPERATIVE MANAGEMENT The rehabilitation program comprises 4-5 phases. Inflammatory phase (weeks 1-2): control of pain and swelling (cooling, isometric tension exercises, 20 kg partial load). Phase 2 (weeks 2-6): increasing load and range of motion with closed chain exercises (target: extension/flexion 0-0-120°). Phase 3 (from week 6): strength and coordination exercises. Phase 4: balance, strength and jump exercises. Return to competitive sport not before postoperative month 6-10. RESULTS Included were 51 patients with recurrent instability after ACL surgery where primary ACL replacement was performed with ipsilateral bone quadriceps tendon graft or contralateral semitendinosus-gracilis graft. All patients had anatomical or non-anatomical tunnel locations without significant widening (>11 mm). After 2 years, the side-to-side difference for anterior tibial translation measured with the KT 1000 arthrometer was 2.0 ± 1.2 mm for the quadriceps group and 3.0 ± 2.9 mm for the semitendinosus-gracilis group (P = 0.461). No difference in the rate of positive pivot shift tests (P = 0.661); no significant difference in the individual Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores or in the frequency of anterior knee pain.
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Affiliation(s)
- W Petersen
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland.
| | - K Karpinski
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland
| | - S Bierke
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland
| | - T Hees
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland
| | - M Häner
- Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Caspar Theysstraße 27-31, 14193, Berlin, Deutschland
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