Showing papers in "Knee Surgery, Sports Traumatology, Arthroscopy in 2018"

Platelet-rich plasma in tendon-related disorders: results and indications

Abstract: Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied. A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies. The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative). Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders. Systematic review of level I–IV trials, Level IV.

Bone marrow concentrate and platelet-rich plasma differ in cell distribution and interleukin 1 receptor antagonist protein concentration

Abstract: Bone marrow concentrate (BMC) and platelet-rich plasma (PRP) are used extensively in regenerative medicine. The aim of this study was to determine differences in the cellular composition and cytokine concentrations of BMC and PRP and to compare two commercial BMC systems in the same patient cohort. Patients (29) undergoing orthopaedic surgery were enrolled. Bone marrow aspirate (BMA) was processed to generate BMC from two commercial systems (BMC-A and BMC-B). Blood was obtained to make PRP utilizing the same system as BMC-A. Bone marrow-derived samples were cultured to measure colony-forming units, and flow cytometry was performed to assess mesenchymal stem cell (MSC) markers. Cellular concentrations were assessed for all samples. Catabolic cytokines and growth factors important for cartilage repair were measured using multiplex ELISA. Colony-forming units were increased in both BMCs compared to BMA (p < 0.0001). Surface markers were consistent with MSCs. Platelet counts were not significantly different between BMC-A and PRP, but there were differences in leucocyte concentrations. TGF-β1 and PDGF were not different between BMC-A and PRP. IL-1ra concentrations were greater (p = 0.0018) in BMC-A samples (13,432 pg/mL) than in PRP (588 pg/mL). The IL-1ra/IL-1β ratio in all BMC samples was above the value reported to inhibit IL-1β. The bioactive factors examined in this study have differing clinical effects on musculoskeletal tissue. Differences in the cellular and cytokine composition between PRP and BMC and between BMC systems should be taken into consideration by the clinician when choosing a biologic for therapeutic application. Clinical, Level II.

Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.

Abstract: The factors affecting the anatomical and functional outcomes of arthroscopic superior capsular reconstruction (ASCR) were investigated in this study. Continuity between the posterior remnant tissue and graft, as well as medial-to-lateral anatomical graft continuity, might play a vital role in shoulder stability and functional recovery, which could be correlated with postoperative factors such as the acromiohumeral distance (AHD). Thirty-two patients (36 shoulders) who underwent ASCR were included. The follow-up period was 24.8 ± 6.9 months. The relationship between graft continuity and preoperative, intraoperative, and postoperative factors that could affect the clinical and radiological outcomes of ASCR were investigated. The American Shoulder and Elbow Surgeons score increased from 50.3 ± 9.1 points preoperatively to 84.0 ± 5.0 points postoperatively (p < 0.01), and the Constant score increased from 56.3 ± 9.0 to 82.8 ± 5.6 points (p = 0.02). Re-tearing occurred in 13 patients during the postoperative follow-up period. The re-tear rate was relatively high (36.1%). The gap between the immediate postoperative and preoperative AHDs was 1.6 ± 2.2 mm in the re-tear (+) group and 3.8 ± 2.8 mm in the re-tear (−) group (p = 0.02). The integrity of the posterior remnant tissue had a statistically significant and different re-tear rate (p < 0.01). Care should be taken in patients with inadequate AHD improvement and poor posterior remnant tissue immediately postoperatively, because the possibility of re-tearing is high. Therefore, better results can be predicted when considering these factors at the time of surgery. IV.

Large correction in opening wedge high tibial osteotomy with resultant joint-line obliquity induces excessive shear stress on the articular cartilage

Abstract: The purpose of this study was to analyse the resultant stress induced by joint-line obliquity after HTO for varus knee deformity using a three-dimensional (3D) finite element model analysis. The geometrical bone data used in this study were derived from commercially available human bone digital anatomy media. The 3D knee models were developed using 3D computer-aided design software. The articular surface was overlaid with a 2-mm-thick cartilage layer for both femoral and tibial condyles. Ligament structures were simulated based on properties reported in previous anatomical studies. Regarding the loading condition, isolated axial loads of 1200 N with lateral joint-line inclinations of 2.5°, 5°, 7.5°, and 10° in reference to the horizontal axis were applied to the femur to simulate the mechanical environment in a knee with joint-line obliquity. A steep rise of shear stress in the medial compartment was noted in the model with obliquity of 5° or more. This laterally directed shear stress exhibited an incremental increase in accordance with the obliquity angle. The maximum shear stress value in the medial cartilage increased from 1.6 MPa for the normal knee to 3.3, 5.2, and 7.2 MPa in the joint-line obliquity models with 5°, 7.5°, and 10° of obliquity, respectively. The effects of HTO for varus knee deformity on the amount/distribution of stresses in the articular cartilage were analysed using a 3D finite element model. It was shown that joint-line obliquity of more than 5° induced excessive shear stress in the tibial articular cartilage. A large amount of correction in OWHTO with a resultant joint-line obliquity of 5° or more may induce detrimental stress to the articular cartilage. Double-level osteotomy should be considered as a surgical option in this situation.

No superior treatment for primary osteochondral defects of the talus.

Abstract: The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults. A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle–Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined. Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78–86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66–85%]. For primary talar osteochondral defects, none of the treatment options showed any superiority over others. IV.

Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study.

Abstract: The purpose of the current prospective study was to assess the changes over time in patients tested at 6 months and 9 months after anterior cruciate ligament reconstruction (ACLR) with a return to sport (RTS) test battery. It was hypothesized that more patients passed RTS criteria at 9 months compared to 6 months. Sixty-two ACLR patients performed a test battery at an average of 6.5 ± 0.7 and 9.5 ± 0.9 months after ACLR. All patients underwent a standardized rehabilitation protocol. The test battery consisted of the following tests: a jump-landing task assessed with the Landing Error Scoring System (LESS), three single-leg hop tasks (single-leg hop test, triple-leg hop test, side hop test), isokinetic quadriceps and hamstring strength at 60, 180 and 300°/s and two questionnaires (IKDC and ACL–RSI). Cut off criteria were set as Limb Symmetry Index (LSI) > 90% (for isokinetic strength and for single-leg hop tasks), LESS 56 respectively. At 6 months, two patients (3.2%) passed all criteria. At 9 months, seven patients (11.3%) passed all criteria. Patients improved in all RTS criteria over time except for the IKDC score. Twenty-nine patients (46.8%) did not pass the strength criterion at 60°/s at 9 months after ACLR. The percentages of patients passing all RTS criteria were low at both 6 and 9 months after ACLR. Quadriceps strength revealed persistent deficits and the lack of improvement in the IKDC score questionnaires shows insufficient self-reported knee function for RTS. III.

Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert

Abstract: The purpose of this study is to propose recommendations for the treatment of patients with chronic lateral ankle instability (CAI) based on expert opinions. A questionnaire was sent to 32 orthopaedic surgeons with clinical and scientific experience in the treatment of CAI. The questions were related to preoperative imaging, indications and timing of surgery, technical choices, and the influence of patient-related aspects. Thirty of the 32 invited surgeons (94%) responded. Consensus was found on several aspects of treatment. Preoperative MRI was routinely recommended. Surgery was considered in patients with functional ankle instability after 3–6 months of non-surgical treatment. Ligament repair is still the treatment of choice in patients with mechanical instability; however, in patients with generalized laxity or poor ligament quality, lateral ligament reconstruction (with grafting) of both the ATFL and CFL should be considered. Most surgeons request an MRI during the preoperative planning. There is a trend towards earlier surgical treatment (after failure of non-surgical treatment) in patients with mechanical ligament laxity (compared with functional instability) and in high-level athletes. This study proposes an assessment and a treatment algorithm that may be used as a recommendation in the treatment of patients with CAI. V.

Over 90 % of children and adolescents return to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Abstract: To evaluate the rate at which children and adolescent athletes return to sporting activities after anterior cruciate ligament (ACL) reconstruction. Three databases, PubMed, MEDLINE, and EMBASE, were searched from database inception until September 9, 2017 by two reviewers independently and in duplicate. The inclusion criteria were English language studies that reported return to sport outcomes. Book chapters, conference papers, review articles, and technical reports were excluded. The rate of return to sports was combined in a meta-analysis of proportions using a random-effects model. Overall, 20 studies with a combined total of 1156 ACL reconstructions met the inclusion criteria, with a mean age of 14.3 years (range 6–19) and a mean follow-up time of 6.5 years (range 1–22). All studies were level IV evidence (14 retrospective case series and 6 prospective case series). The pooled rate of return to any sport participation was 92.0% [95% confidence interval (CI), 86–96%]. The pooled rate of return to pre-injury level of sport was 78.6% (95% CI 71–86%) and that to competitive level of sport was 81.0% (95% CI 62–94%). A total of 93 of the 717 assessed athletes (13%) sustained re-injuries with graft ruptures, and in 91 of 652 patients (14%), contralateral ACL injuries were reported on final follow-up. Pooled results suggest a high rate of return to sport following ACL reconstruction in children and adolescent athletes; however, this is associated with a relatively high rate of graft rupture and a similar rate of contralateral ACL injury. This study provides clinicians with evidence-based data on the ability of children and adolescent athletes to return to sport after ACL reconstruction, an important consideration for athletes of this population with ACL injuries. IV, systematic review of level IV studies.

Intratendinous adipose-derived stromal vascular fraction (SVF) injection provides a safe, efficacious treatment for Achilles tendinopathy: results of a randomized controlled clinical trial at a 6-month follow-up

Abstract: Although platelet-rich plasma (PRP) injection has shown controversial results for the treatment of Achilles tendinopathy, it remains the most used biological treatment. Recent findings seem to demonstrate that the stromal vascular fraction (SVF) within adipose tissue may counteract the impaired tendon homeostasis. The aim of this study was to prospectively compare the efficacy of PRP and SVF injection for the treatment of non-insertional Achilles tendinopathy. Fourty-four patients were recruited in the study; 23 of them were assigned to the PRP group whereas 21 to the SVF group, treated unilaterally or bilaterally for a total of 28 tendons per group. All patients (age 18–55 years) were clinically assessed pre-operatively and at 15, 30, 60, 120 and 180 days from treatment, using the VAS pain scale, the VISA-A, the AOFAS Ankle-Hindfoot Score and the SF-36 form. The patients were also evaluated by ultrasound and magnetic resonance before treatment and after 4 (US only) and 6 months. Both treatments allowed for a significant improvement with respect to baseline. Comparing the two groups, VAS, AOFAS and VISA-A scored significantly better at 15 and 30 days in the SVF in comparison to PRP group (p < 0.05). At the following time points the scores were not significantly different between the two groups. No correlation has been found between clinical and radiological findings. Both PRP and SVF were safe, effective treatments for recalcitrant Achilles tendinopathy. The patients treated with SVF obtained faster results, thus suggesting that such a treatment should be taken into consideration for those patients who require an earlier return to daily activities or sport. Randomized Controlled Clinical Trial, Level 1.

Strength and functional symmetry is associated with post-operative rehabilitation in patients following anterior cruciate ligament reconstruction

Abstract: To investigate strength and functional symmetry during common tests in patients after anterior cruciate ligament reconstruction (ACLR), and its association with post-operative rehabilitation. At a median 11.0 months post-surgery (range 10–14), 111 ACLR patients were assessed. A rehabilitation grading tool was employed to evaluate the duration and supervision of rehabilitation, as well as whether structured jumping, landing and agility exercises were undertaken. Patients completed the Noyes Activity Score (NSARS), maximal isokinetic knee extensor and flexor strength assessment, and a 4-hop test battery. Limb Symmetry Indices (LSIs) were calculated, presented for the entire group and also stratified by activity level. ANOVA evaluated differences between the operated and unaffected limbs across all tests. Correlations were undertaken to assess the relationship between post-operative rehabilitation and objective test LSIs. The unaffected limb was significantly better (p < 0.0001) than the operated limb for all tests. Only 52–61 patients (47–55%) demonstrated LSIs ≥ 90% for each of the hop tests. Only 34 (30.6%) and 61 (55.0%) patients were ≥ 90% LSI for peak quadriceps and hamstring strength, respectively. Specifically in patients actively participating in jumping, pivoting, cutting, twisting and/or turning sports, 21 patients (36.8%) still demonstrated an LSI < 90% for the single hop for distance, with 37 patients (65.0%) at < 90% for peak knee extension strength. Rehabilitation was significantly associated with the LSIs for all tests. Rehabilitation was significantly correlated with limb symmetry, and lower limb symmetry was below recommended criterion for many community-level ACLR patients, including those already engaging in riskier activities. It is clear that many patients are not undertaking the rehabilitation required to address post-operative strength and functional deficits, and are being cleared to return to sport (or are returning on their own accord) without appropriate evaluation and further guidance. IV.

Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction.

Abstract: To evaluate the results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction in patients with chronic ACL injury. It was hypothesized that patients who underwent combined ACL and ALL reconstruction would exhibit less residual laxity and better clinical outcomes. Two groups of patients were evaluated and compared retrospectively. Both groups consisted only of patients with chronic (more than 12 months) ACL injuries. Patients in group 1 underwent anatomical intra-articular reconstruction of the ACL and patients in group 2 underwent anatomic intra-articular ACL reconstruction combined with ALL reconstruction. The presence of associated meniscal injury, the subjective International Knee Documentation Committee (IKDC) and Lysholm functional outcome scores in the postoperative period, KT-1000 evaluation, the presence of residual pivot shift and graft rupture rate were evaluated. One hundred and one patients who underwent reconstruction of chronic ACL injuries were evaluated. The median follow-up was 26 (24–29) months for group 1 and 25 (24–28) months for group 2. There were no significant differences between groups regarding gender, age, duration of injury until reconstruction, follow-up time or presence of associated meniscal injuries in the preoperative period. Regarding functional outcome scores, patients in group 2 presented better results on both the IKDC (p = 0.0013) and the Lysholm (p < 0.0001) evaluations. In addition, patients in group 2 had better KT-1000 evaluation (p = 0.048) and a lower pivot shift rate at physical examination, presenting only 9.1% positivity versus 35.3% in the isolated ACL reconstruction (p = 0.011). Regarding re-ruptures, group 1 presented 5 (7.3%) cases, and group 2 presented no cases. The combined ACL and ALL reconstruction in patients with chronic ACL injury is an effective and safety solution and leads to good functional outcomes with no increase in complication rate. The clinical relevance of this finding is the possibility to indicate this type of procedure when patients present with more than 12 months after injury for surgery. Level III.

YouTube provides poor information regarding anterior cruciate ligament injury and reconstruction

Abstract: YouTube is a global medium used predominantly by young adults (aged 18–49 years). This study examined the quality of YouTube information regarding ACL injury and reconstruction. YouTube was searched on the 13th of June 2015 for “ACL” and “anterior cruciate ligament” with/without associated terms of “injury”, “reconstruction”, and “surgery”. Videos were evaluated by two independent reviewers [EF (Reviewer 1), (Reviewer 2)] using two recognized information scoring systems (Modified DISCERN (MD) 0–5 and JAMA Benchmark 0–4) and an adaptation of a score designed for written ACL information [ACL Specific Score (ASS) 0–25]. The ASS categorized scores as very good (21–25), good (16–20), moderate (11–15), poor (6–10), and very poor (0–5). Number of views/likes/dislikes, animation, and continent of origin and source (e.g., corporate/educational) were recorded. Correlation of video characteristics with number of views was examined using the analysis of variance (ANOVA) model. Agreement between reviewers was assessed by Interclass Correlation Co-efficient (ICC). Following a filtering process of the 964,770 identified videos, 39 videos were retained. The mean MD score was 2.3 (standard deviation (SD) ±0.9) for Reviewer 1 and 2.2 (SD ±0.9) for Reviewer 2 (ICC = 0.7). The mean JAMA score was 2.5(SD ±0.7) for Reviewer 1 and 2.3 (SD ±0.7) for Reviewer 2 (ICC = 0.8). The mean ASS was 6.3 (SD ±3.5) for Reviewer 1 and 4.6 (SD ±2.9) for Reviewer 2 (ICC = 0.9). Five videos achieved moderate score (13%), while 15 (38%) and 19 (49%) scored as poor and very poor, respectively. There was no correlation between number of views and video quality/video source for any scoring system. The majority of videos viewed on YouTube regarding ACL injury and treatment are of low quality.

Combined arthroscopically assisted coraco- and acromioclavicular stabilization of acute high-grade acromioclavicular joint separations

Abstract: Due to high rate of persisting dynamic posterior translation (DPT) following isolated coracoclavicular double-button technique for reconstruction of the acromioclavicular (AC) joint reported in the literature, an additional acromioclavicular cerclage was added to the procedure. The aim of this study was to evaluate the clinical and radiological results of patients with high-grade AC-joint instability treated with a double TightRope technique with an additional percutaneous acromioclavicular cerclage. Fifty-nine patients (6 f/53 m; median age 38.3 (range 21.5–63.4 years) who sustained an acute high-grade AC-joint dislocation (Rockwood type V) were treated using the above-mentioned technique. At the final follow-up, the constant score (CS), the subjective shoulder value (SSV), the Taft score (TF) and the acromioclavicular joint instability score (ACJI) as well as bilateral anteroposterior stress views with 10 kg of axial load and bilateral modified Alexander views were obtained. At a median follow-up of 26.4 (range 20.3–61.0) months, 34 patients scored a median of 90 (33–100) points in the CS, 90 (25–100) % in the SSV, 11 (4–12) points in the TF and 87 (43–100) points in the ACJI. The coracoclavicular (CC) distance was 12.1 (6.5–19.8) mm and the CC difference 2.0 (0.0–11.0) mm. Two patients (5.8%) showed a complete DPT of the AC joint, and fourteen patients (41.1%) displayed a partial DPT. The overall revision rate was 11.7%. Two patients presented implant irritation, one patient a recurrent instability, and one patient suffered from a local infection. The arthroscopically assisted and image-intensifier-controlled double TightRope technique with an additional percutaneous acromioclavicular cerclage leads to good and excellent clinical results after a follow-up of 2 years. The incidence of persisting dynamic horizontal translation is lower compared to isolated coracoclavicular stabilization. Thus, we recommend using the double TightRope implant with an additional acromioclavicular cerclage. IV.

Larger range of motion and increased return to activity, but higher revision rates following unicompartmental versus total knee arthroplasty in patients under 65: a systematic review

Abstract: Due to the lack of comparative studies, a systematic review was conducted to determine revision rates of unicompartmental and total knee arthroplasty (UKA and TKA), and compare functional outcomes, range of motion and activity scores in patients less than 65 years of age. A literature search was performed using PubMed, Embase, and Cochrane systems since 2000. 27 UKA and 33 TKA studies were identified and included. Annual revision rate (ARR), functional outcomes, and return to activity were assessed for both types of arthroplasty using independent t tests. Four level I studies, 12 level II, 16 level III, and 29 level IV were included, which reported on outcomes in 2224 UKAs and 4737 TKAs. UKA studies reported 183 revisions, yielding an ARR of 1.00 and extrapolated 10-year survivorship of 90.0%. TKA studies reported 324 TKA revisions, resulting in an ARR of 0.53 and extrapolated 10-year survivorship of 94.7%. Functional outcomes scores following UKA and TKA were equivalent, however, following UKA larger ROM (125° versus 114°, p = 0.004) and higher UCLA scores were observed compared to TKA (6.9 versus 6.0, n.s.). These results show that good-to-excellent outcomes can be achieved following UKA and TKA in patients less than 65 years of age. A higher ARR was noted following UKA compared to TKA. However, improved functional outcomes, ROM and return to activity were found after UKA than TKA in this young population. Comparative studies are needed to confirm these findings and assess factors contributing to failure at the younger patient population. Outcomes of UKA and TKA in patients younger than 65 years are both satisfying, and therefore, both procedures are not contraindicated at younger age. UKA has several important advantages over TKA in this young and frequently more active population. IV.

Single-dose local anesthetics exhibit a type-, dose-, and time-dependent chondrotoxic effect on chondrocytes and cartilage: a systematic review of the current literature

Abstract: Many studies have shown that local anesthetics may impede chondrocyte metabolism. However, the influence of a single-dose local anesthetics is controversial. The aim of this metaanalysis was to review the literature for studies investigating the cytotoxic effects of single-dose local anesthetics on chondrocytes and cartilage. A comprehensive literature search was performed using established search engines (Medline, Embase) to identify studies, investigating the influence of single-dose local anesthetics on cartilage. The systematic analysis included the influence on histology, cell viability, morphology, and matrix production depending upon dose, exposure time, and type of local anesthetics. Twelve studies with four different local anesthetics were included in this metaanalysis. Bupivacaine and lidocaine were found to be more chondrotoxic than mepivacaine and ropivacaine. The amount of dead cells increased in a substance-, dose-, and time-dependent process. Osteoarthritic cartilage seems to be more vulnerable compared to intact cartilage. The toxic effects occur first in the superficial cartilage layers and include damage to membrane integrity, mitochondrial DNA, and nuclear changes. There is no study that could show a significant chondrotoxic effect with low concentrations of bupivacaine (0.0625%), ropivacaine (0.1 and 0.2%), and mepivacaine (0.5%). The cytotoxicity of local anesthetics on chondrocytes is dependent on dose, time, and type of local anesthetics. Single-dose intra-articular administration of local anesthetics impede chondrocyte metabolism and should be performed only with low concentrations for selected diagnostic purposes and painful joints. The use of lidocaine should be avoided. II.

There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study.

Abstract: Graft choice for anterior cruciate ligament (ACL) reconstruction is crucial, however the optimal graft source remains a topic of controversy. The purpose of this study is to compare subjective and functional patient-reported outcomes (PRO) after single-bundle ACL reconstruction using quadriceps tendon (QT) or hamstring tendon (HT) autografts for single-bundle ACL reconstruction. We hypothesize that there is no difference in patient-reported functional outcomes after ACL reconstruction using either HT- or QT autograft. All data were extracted from a prospectively collected ACL registry. A total of 80 patients with at least 2-year follow-up were included in this study. A total of 40 patients with primary ACL reconstruction using a QT autograft harvested via a minimally invasive technique were matched by sex, age and pre-injury Tegner and Lysholm score to 40 patients who received HT autografts. Subjective and functional PRO scores including Lysholm score, Tegner activity level and visual analogue scale for pain were obtained at 6, 12 and 24 months after index surgery. No significant difference between the QT and the HT group was seen at any follow-up in regard to any of the PRO scores for function or pain. 24 months post-surgery the mean Tegner activity score of the HT group was significantly (p = 0.04) lower compared to the pre-injury status. At final follow-up, 27 patients (67.5%) in the QT group and 32 patients (80.0%) in the HT returned to their pre-injury activity level (n.s.). A total of 37 patients (92.5%) of the QT cohort and 35 patients (87.5%) of the HT cohort reported “good” or “excellent” results according to the Lysholm score (n.s.). “No pain” or “slight pain” during severe exertion was reported by 33 patients (82.5%) with QT autograft and 28 patients (82.4%) with HT autograft (n.s.). There is no significant difference between PRO 2 years post-operative using either QT or HT autografts. Both QT and HT grafts show acceptable and comparable PRO scores making the QT a reliable graft alternative to HT for primary ACL reconstruction. III.

Kinematically aligned total knee arthroplasty reduces knee adduction moment more than mechanically aligned total knee arthroplasty.

Abstract: Knee adduction moment (KAM) has been recognized as a good clinical surrogate for medial tibiofemoral joint loading and is associated with implant durability after total knee arthroplasty (TKA). This study aimed to examine the effects of joint line obliquity in kinematically aligned TKA (KA-TKA) on KAM during gait. The study enrolled 21 knees from 18 patients who underwent cylindrical axis reference KA-TKA and a matched group of 21 knees from 18 patients who underwent mechanically aligned (MA)-TKA as controls. Gait analyses were performed the day before TKA and at an overall mean of 2.6 years postoperatively. First peak KAM and variables associated with frontal knee kinetics were determined and compared between groups. In KA-TKA, the proximal tibia was resected with 3.4° ± 1.5° of varus in relation to the mechanical axis, and the final femorotibial shaft axis was 176.7° ± 3.8° with KA-TKA and 174.4° ± 3.0° with MA-TKA. KAM was significantly smaller with KA-TKA than with MA-TKA (p < 0.032). Regarding variables affecting KAM, significant differences were evident between the two TKAs for knee adduction angle (p = 0.0021), lever arm (p = 0.028), and Δlever arm (p = 0.0001). In KA-TKA, joint line obliquity reduced peak KAM during gait, despite slight varus limb alignment, and this reduced KAM in KA-TKA can tolerate constitutional varus alignment. In clinical settings, KA-TKA thus represents a promising technical option for patients with large coronal bowing of the shaft carrying a risk of increased KAM after TKA. III.

Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction

Abstract: The aim of this study was to compare isokinetic quadriceps and hamstring muscle strength in patients following anterior cruciate ligament (ACL) reconstruction who received either hamstring (HT) or quadriceps (QT) tendon autografts at two time intervals within the first year after surgery. One hundred twenty-four patients, 81 males (age 22.0 ± 6.2 years) and 43 females (age 20.9 ± 8.7 years), participated in this study. ACL reconstruction was performed with either quadriceps tendon autografts (QT; n = 61) or hamstring tendon autografts (HT; n = 63). Two isokinetic muscle strength tests (t1: 5.5 ± 1.2 months; t2: 7.6 ± 1.6 months) were performed at an angular velocity of 60°/s in both the injured and contralateral knees. An independent t test as well as a two-factor analysis of variance with repeated measurements was used. The significance level was set at p < 0.05. A statistically significant lower knee extensor strength was observed in the QT group within one year after surgery (p < 0.001). Additionally, data showed a significant higher H/Q ratio in QT patients compared to the HT group at t1 (p < 0.001) and t2 (p = 0.001) as well as a significant effect over time (p < 0.001) and interaction effect of time and graft (p = 0.007). Side-to-side values for extensor muscle strength were significantly (p < 0.001) greater in HT graft patients, while QT patients showed significantly (p < 0.001) greater values for flexor muscle strength at both time points of isokinetic testing, respectively. The results of this study indicate that graft choice has an impact on extensor strength in the first months after ACL reconstruction; however, there is no impact on flexor strength. The finding of a higher H/Q ratio in patients with QT grafts within the first months following surgery is possibly of clinical relevance. This may potentially be associated with lower stress on the maturing ACL graft. Furthermore, normal thigh strength can be restored over time. III.

The Shoulder Instability-Return to Sport after Injury (SIRSI): a valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability

Abstract: The main goal of this study was to propose and validate a tool to quantify the psychological readiness of athletes to return to sport following traumatic shoulder instability and conservative or surgical management. «Knee» was replaced by the term «shoulder» in the Anterior Cruciate Ligament-Return to Sport after Injury scale. This pilot test of the Shoulder Instability-Return to Sport after Injury scale (SIRSI) was performed in a group of athletes who underwent surgery for post-traumatic chronic anterior shoulder instability. The final version was then validated according to the international COSMIN methodology. A retrospective study was performed including all rugby players who had reported an episode of instability between 2012 and 2013. The WOSI and the Walch-Duplay scales were used as reference questionnaires. Sixty-two patients were included, mean age 26 ± 5.2 years old, 5 women/57 men. Patients were professional or competitive athletes (70.9%) and followed-up for 4.6 ± 1.6 years after the first episode of shoulder instability. Shoulder surgery was performed in 30/62 (48.4%) patients, a mean 1.6 ± 1.2 years after the first episode of instability. The SIRSI was strongly correlated with the reference questionnaires (r = 0.80, p < 10−5). The mean SIRSI score was significantly higher in patients who returned to play rugby (60.9 ± 26.6% vs 38.1 ± 25.6%, p = 0.001). The internal consistency of the scale was high (α = 0.96). Reproducibility of the test–retest was excellent (ρ = 0.93, 95% CI [0.89–0.96], p < 10−5). No ceiling/floor effects were found. The SIRSI is a valid, reproducible scale that identifies patients who are ready to return to the same sport after an episode of shoulder instability, whether they undergo surgery or not. III.

Intra-articular injections of expanded mesenchymal stem cells with and without addition of platelet-rich plasma are safe and effective for knee osteoarthritis.

Abstract: To compare the effectiveness and safety of intra-articular injections of autologous expanded mesenchymal stromal stem cells alone (MSCs), or in combination with platelet-rich plasma (MSCs + PRP), in patients with knee osteoarthritis. Eighteen patients (57.6 ± 9.6 years) with radiographic symptomatic knee osteoarthritis (Dejour grades II–IV) were randomized to receive intra-articular injections of MSCs (n = 9) or MSCs + PRP (n = 9). Injections were performed 2–3 weeks after bone marrow aspiration (± 80–100 ml) which was obtained from both posterior iliac crests. The Knee Injury and Osteoarthritis Outcome Score (KOOS) improved significantly throughout the 12 months for both groups (p < 0.05). No statistically significant differences between groups were found in KOOS subscales and global score improvements at 12-month end-point (n.s.). The MSCs group showed significant improvements in the pain, function and daily living activities, and sports and recreational activities subscales (p < 0.05). Similarly, the MSCs + PRP group showed significant improvements in the pain, function and daily living activities and quality of life subscales (p < 0.05). The average number of fibroblast colony forming units (CFU-F) was 56.8 + 21.9 for MSCs group and 50.7 ± 21.7 for MSCs + PRP group. Minimal adverse effects were seen in both groups (10 adverse events, in 5 patients). Intra-articular injections of expanded MSCs alone or in combination with PRP are safe and have a beneficial effect on symptoms in patients with symptomatic knee osteoarthritis. Adding PRP to the MSCs injections did not provide additional benefit. These results are encouraging and support the recommendation of this minimally invasive procedure in patients with knee osteoarthritis, without requiring hospitalization. The CFU-F results may be used as reference for future research. Prospective cohort study, Level II.

Measurement properties of the most commonly used Foot- and Ankle-Specific Questionnaires: the FFI, FAOS and FAAM. A systematic review

Abstract: In the foot and ankle literature, a wide range of patient-reported outcome measures (PROMs) is used, however, consensus as to which PROMs are preferred is lacking. Selection of a PROM is among other reasons, often based on measurement properties without considering the methodological quality of the studies that evaluate these measurement properties. The aim of current study was first to identify the most frequently used foot and ankle-specific PROMs in recent orthopaedic foot and ankle literature, and second to conduct a systematic review to synthesize and critically appraise the measurement properties of these PROMS. Six PubMed indexed journals focussing on foot and ankle research were screened to identify most commonly used foot and ankle-specific PROMs over a 2 year period (2015–2016). Subsequently, a systematic literature search was performed in PubMed, EMBASE, SPORTDiscus and Scopus to identify relevant studies on their measurement properties. Methodological quality assessment was performed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist, criteria for good measurement properties were applied, and a level of evidence was determined for the measurement properties of each domain of the questionnaires. The three most frequently reported PROMs were the Foot Function Index (FFI), the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Activity Measure (FAAM). Among 2046 unique citations, 50 studies were included evaluating these PROMs. Evidence to support the measurement properties of the FFI was mainly lacking due to poor methodological quality. More evidence was available for the measurement properties of the FAOS and the FAAM, but overall evidence supporting all measurement properties is not yet sufficient. The best available evidence retrieved in this review showed that the FAOS and the FAAM are promising outcome measures for evaluation of patients with foot and ankle conditions, but their shortcomings should be taken into account when interpreting results in clinical setting or trials. I.

Trochleoplasty techniques provide good clinical results in patients with trochlear dysplasia

Abstract: The aim of this systematic review is to compare the clinical outcomes of patients treated with different trochleoplasty procedures, the rate of complications and recurrence of patellar dislocation. A systematic review of the literature was performed, in accord with the PRISMA guidelines. PubMed, MEDLINE, CINAHL, Cochrane, EMBASE and Google Scholar databases were comprehensively searched using the keyword combinations, “Dejour trochleoplasty”, “Bereiter Trochleoplasty”, “Albee Trochleoplasty”, “Recession Trochleoplasty”, “Trochlear Dysplasia”, “Instability”, “Adult”, “Clinical Outcome” and “Surgery”. Three-hundred and ninety-two knees in 371 patients were included. Bereiter U-shaped deepening trochleoplasty was the most commonly used technique for the treatment of trochlear dysplasia in the included studies with the lowest rate of recurrence and post-operative ROM deficiency. On the other hand, Dejour V-shaped deepening trochleoplasty showed the highest mean post-operative value of Kujala score with 79.3 (SD 8.4) points. Statistical differences were found in terms of redislocation rate between Goutallier procedure and Bereiter trochleoplasty (p < 0.05) and in terms of post-operative osteoarthritis between Bereiter and Dejour procedures (p < 0.05). Bereiter trochleoplasty seems to be the most efficiency procedure in terms of post-operative patellar redislocation, post-operative osteoarthritis and ROM, but the highest mean post-operative Kujala score is obtained by Dejour procedure. Therefore, none of the surgical techniques analysed highlighted a real superiority. Randomised clinical trials are needed to establish whether of available surgical technique is the best to treat patient with trochlear dysplasia. The clinical relevance of this paper is that the three most popular trochleoplasty techniques are associated with significantly improved stability and function, showing a relatively low rate of osteoarthritis and pain, and a moderate rate of complications. Systematic review, Level IV.

Tibial internal rotation negatively affects clinical outcomes in total knee arthroplasty: a systematic review

Abstract: The aim of this systematic review is to analyze the effect of tibial rotational alignment after total knee arthroplasty (TKA) on clinical outcomes and assess the eventual cut-off values for tibial TKA rotation leading to poor outcomes. A detailed and systematic search from 1997 to 2017 of the Pubmed, Medline, Cochrane Reviews, and the Google Scholar databases was performed using the keyword terms “total knee arthroplasty”, “total knee replacement”, “tibial alignment”, “tibial malalignement”, “tibial rotation”, “rotational error”, “axis”, “angle”, “tibial malrotation”, “clinical outcome”, in several combinations. The modified Coleman scoring methodology (mCMS) was used. All the primary TKAs studies analyzing correlation between clinical results and tibial rotation were included. Five articles met the inclusion criteria. A total of 333 arthroplasties were included in this review; 139 had tibial component malalignment, while 194 were in control groups. The mean age of patients was 67.3 (SD 0.57) years. The mean average postoperative follow-up delay was 34.7 months (range 21–70). The mean mCMS score was 59.2 points indicating good methodological quality in the included studies. Functional outcomes were assessed through KSS, OKS, KOOS and VAS, negatively related to tibial internal rotation. Our review confirmed that excessive internal rotation of the tibial TKA component represents a significant risk factor for pain and inferior functional outcomes after TKA (> 10° of internal rotation demonstrated the common value), since external rotation does not affect the results. However, a universal precise cut-off value has not been found in the available literature and there remains a debate about CT rotation assessment and surgical intra-operative landmarks. III.

Satisfactory functional and radiological outcomes can be expected in young patients under 45 years old after open wedge high tibial osteotomy in a long-term follow-up.

Abstract: To report the long-term outcomes of medial open wedge high tibial osteotomy (MOWHTO) for the treatment of medial compartment knee osteoarthritis in patients younger than 45 years old. It was hypothesized that the correction of knee alignment would result in preservation of knee function in a long-term follow-up. Patients under 45 years old, who underwent MOWHTO for symptomatic medial compartment knee osteoarthritis between 2001 and 2005 were retrospectively reviewed after a minimum of 10 years. The osteotomy was performed utilizing a locking plate without the use of bone graft. Patients were evaluated pre- and postoperatively using the International Knee Documentation Committee Score, the Oxford Knee Score, the Knee injury Osteoarthritis Outcome Score and the Short Form-12 Score. Standardized standing whole-limb radiographs were also obtained to assess mechanical tibiofemoral angle (mTFA) and the grade of osteoarthritis. A total of 20 patients (18 males, 2 females, mean age 35.4 years) with a mean follow-up of 12.3 years were included in the study. During the follow-up period, one patient required conversion to total knee replacement (95% survival rate). All clinical outcome scores (IKDC, KOOS, OKS, and SF-12) significantly improved postoperatively (p < 0.05), with no significant deterioration over time. Preoperative varus alignment with an mTFA of − 5.8 ± 2.4° was corrected to 2.5 ± 1.9° immediately after surgery (p < 0.05), and remained 2.2 ± 1.7° at the last follow-up. Furthermore, no significant radiographic progression of osteoarthritis was observed. MWOHTO with a locking plate is an effective joint preservation method to treat medial compartment OA in active patients less than 45 years. Clinical and radiological results are satisfactory and the survival rate is 95%, 12 years after the procedure. Level IV therapeutic, retrospective, cohort study.

Ten-year patient-reported outcomes following total and minimally invasive unicompartmental knee arthroplasty: a propensity score-matched cohort analysis

Abstract: For patients with medial compartment arthritis who have failed non-operative treatment, either a total knee arthroplasty (TKA) or a unicompartmental knee arthroplasty (UKA) can be undertaken. This analysis considers how the choice between UKA and TKA affects long-term patient-reported outcome measures (PROMs). The Knee Arthroplasty Trial (KAT) and a cohort of patients who received a minimally invasive UKA provided data. Propensity score matching was used to identify comparable patients. Oxford Knee Score (OKS), its pain and function components, and the EuroQol 5 Domain (EQ-5D) index, estimated on the basis of OKS responses, were then compared over 10 years following surgery. Mixed-effects regressions for repeated measures were used to estimate the effect of patient characteristics and type of surgery on PROMs. Five-hundred and ninety UKAs were matched to the same number of TKAs. Receiving UKA rather than TKA was found to be associated with better scores for OKS, including both its pain and function components, and EQ-5D, with the differences expected to grow over time. UKA was also associated with an increased likelihood of patients achieving a successful outcome, with an increased chance of attaining minimally clinically important improvements in both OKS and EQ-5D, and an ‘excellent’ OKS. In addition, for both procedures, patients aged between 60 and 70 and better pre-operative scores were associated with better post-operative outcomes. Minimally invasive UKAs performed on patients with the appropriate indications led to better patient-reported pain and function scores than TKAs performed on comparable patients. UKA can lead to better long-term quality of life than TKA and this should be considered alongside risk of revision when choosing between the procedures. II.

Similar clinical outcomes following collagen or polyurethane meniscal scaffold implantation: a systematic review.

Abstract: The purpose of this systematic review is to evaluate the current literature in an effort to assess specific clinical outcomes following meniscal scaffold implantation using the two available scaffolds: Collagen Meniscal Implant (CMI) and the Actifit polyurethane meniscal scaffold. A systematic review was performed by searching PubMed, Embase, and Cochrane Library to find studies evaluating clinical outcomes of patients undergoing meniscal scaffold implantation. Search terms used were “meniscus”, “meniscal”, “scaffold”, and “implant”. Studies were evaluated based on scaffold type, treatment failure rates, patient-reported outcome scores, concomitant procedures, and radiological findings. Radiological findings were recorded using the Genovese scale to assess morphology and signal intensity and the Yulish score to assess articular cartilage. Nineteen studies (1 level I, 1 level II, 17 level IV evidence) were identified that met inclusion criteria, including a total of 658 patients (347 Actifit, 311 CMI). The overall average follow-up was 45 months. Treatment failure occurred in 9.9% of patients receiving the Actifit scaffold at a mean follow-up of 40 months and 6.7% of patients receiving CMI at a mean follow-up of 44 months (n.s.). However, the rate of failure ranged from 0 to 31.8% amongst the included studies with a variable definition of failure. Additionally, overlapping patients and presence of concomitant surgeries such as anterior cruciate ligament reconstruction (ACLR) and high tibial osteotomy (HTO) may have a significant influence on these results. Outcomes for the Visual Analog Scale (VAS) for pain, Lysholm knee score, and Tegner activity score improved from preoperatively to latest follow-up in both groups, while the Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee scores improved from preoperatively to latest follow-up for Actifit scaffold patients. Overall, patients receiving CMI scaffolds had higher grades for Genovese morphology and signal intensity when compared to Actifit scaffold patients. Patients undergoing meniscal scaffold implantation with either CMI or Actifit scaffold can both be expected to experience improvement in clinical outcomes when used in association with concomitant procedures such as ACLR and HTO. IV, systematic review.

Repair of the lateral posterior meniscal root improves stability in an ACL-deficient knee.

Abstract: To investigate the stabilizing effect of a lateral meniscus posterior root repair in an ACL and root deficient knee. The hypothesis of the current study was that a sequential transection of the posterior root and the meniscofemoral ligaments in an ACL-deficient knee increases rotational instability, and conversely, a repair of the meniscus root reduces the internal tibial rotation. Therefore, eight human knee joints were tested in a robotic setup (5 N m internal torque, 50 N m anterior translation load). Five conditions were tested: intact, ACL cut, ACL cut + lateral meniscus posterior root tear (LMRT), ACL cut + LMRT + transection of the MFL and ACL cut + lateral meniscus root repair. The angles of internal tibial rotation as well as anterior tibial translation were recorded. Transection of the lateral meniscus posterior root increased the internal tibial instability as compared to the ACL-insufficient state. A significant increase was detected in 60° and 90° of flextion. Sectioning of the meniscofemoral ligament further destabilized the knees significantly at all flexion angles as compared to the ACL-deficient state. Even in 30°, 60° and 90° a significant difference was detected as compared to the isolated root tear. A tibial fixation of the lateral meniscus root reduced the internal tibial rotation in all flexion angles and led to a significant decrease of internal tibial rotation in 30° and 90° as compared to the transection of the root and the MFL. The anterior tibial translation was increased in all conditions as compared to the native state. A lateral meniscus root repair can reduce internal tibial rotation in the ACL-deficient knee. To check the condition of the lateral posterior meniscus root attachment is clinical relevant as a lateral meniscus root repair might improve rotational stability.

Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up.

Abstract: This study investigated the long-term results of arthroscopic Bankart repair in terms of rates and timelines of recurrence of instability, with special interest in young adult patients aged ≤20 years. Between 2000 and 2005, 186 shoulders [182 patients, 50 women, median age 26 (range 15–58) years] were operated on at a university hospital using arthroscopic Bankart repair because of instability after traumatic anteroinferior shoulder dislocation. Medical records were retrospectively reviewed and patients were assessed using postal questionnaires or telephone interview after a minimum of 10 years of follow-up [median 12.2 (range 10–16) years]. The primary outcome measure was recurrence of instability (assessed from 167 shoulders), other outcome measures included Oxford instability score (OIS), subjective shoulder value (SSV), and Western Ontario instability index (WOSI) (assessed from 157 shoulders). At the end of follow-up, 50/167 shoulders (30%) had recurrence of instability and 30/167 (18%) were subjected to reoperation due to instability symptoms. Twenty-six (52%) failures occurred within ≤2 years, 11 (22%) within 2–5 years, and 13 (26%) >5 years after surgery. Failure rate was 19/35 (54%) for patients aged ≤20 years and 31/132 (24%) for patients aged >20 years; reoperation rates were 11/35 (31%) and 19/132 (14%), respectively. Mean OIS was 20 (SD 9, range 12–50), SSV 83% (SD 21, range 10–100), and WOSI score 80 (SD 22, range 33–100). Nearly one-third of patients had recurrence of instability after arthroscopic Bankart repair after a minimum of 10-year follow-up. Patients aged ≤20 years did poorly with more than half of the patients having recurrence; alternative stabilization techniques should probably be considered for these patients. IV.

Neuromuscular exercises prevent severe knee injury in adolescent team handball players

Abstract: Team handball is associated with a high risk of severe knee injury that needs to be reduced, particularly at the youth level. The purpose of this study was to show how an injury-prevention programme effectively reduces severe knee injury in adolescent team handball players. Of 23 adolescent handball teams of both sexes, 13 were randomly allocated into the intervention group (168 players) and 10 into the control group (111 players). Players of the intervention group regularly participated in an injury-prevention programme for one season. Handball exposure and sustained injuries were documented for both groups on a monthly basis. The primary outcome parameter of the injury-prevention programme was the incidence of severe knee injury. Of the 279 included players, 68 (24%) sustained 82 injuries yielding an overall incidence of 1.85 injuries per 1000 h handball exposure (intervention group: 50 injuries/incidence: 1.90/1000 h; control group: 32 injuries/incidence: 1.78/1000 h). Knee injury was the second most frequent injury in adolescent team handball. The primary outcome parameter, severe knee injury occurred significantly more often in the control group [mean age (SD) 15.1 (1.0), injury incidence 0.33/1000 h] than in the intervention group [mean age (SD) 14.9 (0.9), injury incidence 0.04/1000 h]. The odds ratio was 0.11 (95% CI 0.01–0.90), p = 0.019. Other injuries to the lower extremities showed no significant difference between the two groups. Frequent neuromuscular exercises prevent severe knee injury in adolescent team handball players and should thus be included in the practical routine as well as in the education of team coaches.

Increased extrusion and ICRS grades at 2-year follow-up following transtibial medial meniscal root repair evaluated by MRI

Abstract: The purpose of the current study was to evaluate the short-term results of meniscal root repair surgery, assessing clinical and radiographic outcomes, utilizing MRI to assess root healing and extent of post-operative extrusion. This was a single-center, retrospective study evaluating patients who had undergone a medial meniscus posterior root repair using a transtibial pullout technique with two locking cinch sutures. Demographic data were collected from patient charts. Clinical outcomes were assessed with pre- and post-operative IKDC and Lysholm scores. Pre-op scores were taken at the patients’ initial clinical visit, mean 1.55 months prior to surgery (± 1.8 months, min 0.3, max 7.3). Radiographic outcomes were assessed with MRI evaluation of root healing, meniscal extrusion, and cartilage degeneration using ICRS criteria. Tunnel placement was evaluated and compared to the anatomic footprint. Eighteen patients (47.2 years ± 11.9) were evaluated at mean follow-up of 24.9 months (± 7.2, min 18.4, max 35.6). The IKDC score significantly increased from 45.9 (± 12.6) pre-operatively to 76.8 (± 14.7) post-operatively (p 3 mm of extrusion on pre-operative MRI had < 3 mm of extrusion on post-operative MRI. Both medial femoral condyle and medial tibial plateau ICRS grades worsened significantly (p < 0.02 and p < 0.01, respectively). On MRI, one root appeared completely healed, 16 partially healed, and one not healed. Patients treated with the transtibial suture pull-out technique with two locking cinch sutures had improved clinical outcomes, but only partial healing in the majority of cases, increased extrusion, and progression of medial compartment cartilage defect grade on follow-up MRI. Patients should be counseled that although clinical outcomes in the short term may be optimistic, long-term outcomes regarding progression to degenerative arthritis may not be as predictable. III.