The purpose of the study was to determine the prevalence of proximal tibiofibular joint (PTFJ) dislocations in knee dislocations classified as Schenck type ≥III and to compare with uninjured contralateral knees, which served as control cohort.
Patients treated at Cologne Merheim Medical Center with knee dislocation ≥III between 2015 and 2022 were included, while one control group consisted of uninjured contralateral knees. In addition to established PTFJ-specific parameters, two novel computed tomography-based PTFJ parameters were implemented on scans obtained a mean of 5 days post-trauma. The fibula lateralisation quantifies the lateral shift of the proximal fibula joint line in relation to the tibial PTFJ joint line. The posterior fibula area quantifies the fibula position in the sagittal plane with reference to the posterior tibial margin.
A total of 107 knee joints were included, comprising 40 with knee dislocation ≥III, 24 uninjured contralateral knees and 43 chronically isolated anterior cruciate ligament insufficient knees. The overall cohort had a median posterior fibula area of 92.7% and a fibula lateralisation of 0.0%. Complete PTFJ dislocation was observed in 5.4% of knee dislocation cases, all in type IV injuries. Fibula lateralisation analysis indicated PTFJ subluxation in an additional 21.6% of cases. No PTFJ dislocations were present in the contralateral knee group. The knee dislocation group differed significantly from the matched contralateral knee group with regard to fibula lateralisation (r = 0.43; p = 0.007), whereas no differences were observed for inclination-horizontal (p = 0.620), inclination-fibular axis (p = 0.082) and obliquity (p = 0.602).
This study demonstrates a 5.4% prevalence of PTFJ dislocation in knee dislocations ≥III, which is lower than previously reported. The incidence of PTFJ dislocation in knee dislocations type IV is high at 33.3%. Fibula lateralisation and posterior fibula area are suitable parameters for assessing anterolateral dislocation of the proximal fibula. Inclination-horizontal, inclination-fibular axis and obliquity show no relevant side-to-side differences in individuals.
Level III.
Young athletes undergoing anterior cruciate ligament reconstruction (ACLR) are at high risk of graft failure and contralateral anterior cruciate ligament (CACL) injury, despite advances in surgical technique. Lateral extra-articular tenodesis (LET) has emerged as a potential adjunct to improve graft survivability in high-risk young populations. The study aimed to describe graft survival, CACL rates, patient-reported outcome measures (PROMs) and return-to-sport (RTS) outcomes in high-risk under-20 athletes undergoing ACLR and LET.
This retrospective cohort study analysed U20 athletes who underwent primary ACLR with hamstring tendon autografts and concurrent LET between 2017 and 2023. All surgeries were performed by a single surgeon using a standardized technique. Outcomes included graft survivability, CACL injury incidence, and RTS level, with functional recovery assessed via the Marx Activity Scale and Tegner–Lysholm Score. Kaplan–Meier survival analysis, independent t-tests, χ2 tests, and multivariate logistic regression were used to evaluate outcomes and identify predictors, with significance set at p < 0.05.
One hundred fifty-nine patients (mean age 17.6 ± 1.9 years) were included, with a mean follow-up of 49.7 ± 18.8 months. Graft rerupture occurred in 2.5% of patients, all within 40 months postoperatively. CACL injury was observed in 12.6% of patients. Over 60% of athletes returned to their pre-injury level of sport, with higher PROMs in those achieving same-level RTS. A smaller graft diameter was significantly associated with increased risk of CACL injury (p < 0.05). LET was not associated with adverse effects on functional recovery.
This cohort showed low graft rerupture rates, favourable functional outcomes and encouraging RTS levels following ACLR and LET. However, CACL injury remained a substantial concern. LET may be considered in adolescent athletes participating in pivoting sports to potentially reduce graft failure, although further comparative studies are needed.
Level IV.
The incidence of anterior cruciate ligament (ACL) injuries in paediatric and skeletally immature patients is rising, proportionally to the worldwide spread of sport participation. However, differently from adults, injuries in young patients pose serious challenges regarding their management, especially when surgery is required. To date, controversies remain regarding the indications, timing of surgery and techniques for ACL reconstruction. This current concept provides a deep and detailed theoretical background of ACL injury and management in patients with open physis. Moreover, a practical algorithm of treatment is provided based on authors' experience and research and current evidence-based medicine (EBM). To optimise management and reduce the risks of either conservative or surgical treatment, a deep knowledge of the specific concepts related to paediatric patients is required.
Level V.
While distinct in incidence and presentation, both talus and calcaneus fractures share a common challenge in their complex anatomy and high-energy mechanisms resulting in difficulties in treatment. With traditional open reduction and internal fixation (ORIF), these fractures carry a high risk of complications, such as avascular necrosis, infection and post-traumatic arthritis. New minimally invasive strategies have risen to the forefront, with arthroscopic-assisted reduction and internal fixation (ARIF) emerging as a promising alternative. This technique offers the potential for enhanced visualisation, reduced soft-tissue disruption, quicker recover and greater reduction advantage. The purpose of this narrative review was to discuss outcomes and surgical techniques of arthroscopic-assisted reduction and internal fixation (ARIF) of talus and calcaneus fractures. ARIF techniques varied in patient positioning, portal use and fixation strategies, but consistently emphasised anatomic reduction via microscopic visualisation typically with temporary Kirshner wires, followed by fixation with cannulated screws. Despite the technical learning curve, the use of ARIF demonstrated clear advantages in minimising soft-tissue trauma and enhancing joint preservation in both talus and calcaneus fractures. This review supports the growing role of minimally invasive techniques as a viable alternative to ORIF in patients with high-energy talus and calcaneus fractures.
Level IV.
Hip arthroscopy (HAS) research employs a wide range of patient-reported outcome measures (PROMs). This heterogeneity complicates cross-study comparisons and meta-analyses, as no gold-standard PROM exists. The minimal clinically important difference (MCID) offers a clinically meaningful threshold of change, but methodological guidance on integrating heterogeneous PROMs through MCID has been lacking. Can heterogeneous PROMs in HAS be harmonized through MCID normalization? PROMs reported in 100 HAS studies were identified and ranked according to frequency of use. The most frequently reported MCID values from published validation studies were applied. Each PROM was then evaluated and normalized by dividing observed mean values and standard deviations by the respective MCID, thereby yielding a standardized metric expressed in ‘MCID units’. A proof-of-concept data set with seven simulated two-arm studies was created to demonstrate the stepwise process of PROM prioritization, MCID-based normalization and subsequent synthesis through random-effects meta-analysis using the restricted maximum likelihood (REML) estimator. Across the 100 included studies, 214 PROM mentions were identified, with modified Harris Hip Score (mHHS) (33.2%), International Hip Outcome Tool—12 items (iHOT-12) (16.4%) and Hip Outcome Score—Sports Subscale (HOS-SSS) (15.4%) being the most frequent. Normalization successfully transformed heterogeneous PROMs into a unified outcome scale, enabling synthesis of results as ‘number of clinically meaningful improvements’. The framework preserved clinical interpretability and allowed transparent, reproducible pooling of outcomes. A proof-of-concept data set of seven simulated studies illustrated stepwise MCID-based normalization and synthesis through random-effects meta-analysis (REML). MCID normalization may offer a robust and clinically relevant methodology to harmonize diverse PROMs in HAS research. Its application may enhance comparability, reduce bias in evidence synthesis and support meaningful interpretation of meta-analytic findings. Importantly, it translates heterogeneous PROMs into a unified, clinically interpretable metric, thereby helping clinicians and researchers to better assess treatment effectiveness across studies. This approach could also be adapted to other surgical fields with fragmented outcome reporting.
Level V, expert opinion.
This study aimed to evaluate the time-dependent changes in the medial and lateral subchondral bone density distribution of the tibial joint surface before and after high tibial osteotomy (HTO) using computed tomography-osteoabsorptiometry.
This study included 17 patients (20 knees) (8 men and 9 women; mean age: 55 years) who underwent HTO for medial compartment osteoarthritis. Computed tomography-osteoabsorptiometry was conducted to measure the subchondral bone density distribution in the tibial joint surface. The high-density area (HDA), defined as the region corresponding to the highest Hounsfield unit values that comprises 20% of the total region, was calculated. Medial ratio was defined as the proportion of the HDA in the medial compartment relative to the total HDA of both compartments. Measurements were performed preoperatively and at 3, 6, 12 and 24 months post-operatively, and a generalized linear regression analysis with a gamma distribution model was conducted.
The medial ratios (mean ± standard deviation) were 89 ± 9% preoperatively, 73 ± 12% at 3 months, 78 ± 13% at 6 months, 78 ± 10% at 12 months and 77 ± 17% at 24 months. Based on the gamma distribution, the non-linear model was expressed as follows: Y = 82.8 × t−0.04 × exp(−0.004 × t). This finding indicated that the medial ratio had a decreasing trend, reaching its minimum at 10.2 months post-operatively.
This study showed time-dependent changes in the subchondral bone density on the tibial side after HTO. The changes in the bone density distribution on the medial and lateral tibial joint surface, which are associated with alignment correction, stabilized at approximately 10.5 months post-operatively. Therefore, the optimal timing for evaluating subchondral bone density in response to stress redistribution may be after 10.2 months.
Level IV.
Chronic ankle instability (CAI) is a common condition characterized by recurrent episodes of lateral instability, often due to a lesion of the ankle collateral lateral ligament complex. If untreated, CAI can lead to persistent symptoms and long-term degenerative changes. Arthroscopic ‘all-inside’ repair has gained traction as a minimally invasive technique offering functional and clinical benefits.
This retrospective study analyzed 43 patients undergoing arthroscopic ligament repair using the all-inside technique between 2021 and 2024. Functional outcomes were evaluated preoperatively (T0), post-rehabilitation (T1), and at the final follow-up (T2) using the Foot and Ankle Ability Measure (FAAM) score, VAS, and satisfaction ratings. Complications occurred were recorded during the follow up. Subgroup analyses investigated the influence of BMI, anchor use, and preoperative functional scores on outcomes.
Patients demonstrated significant improvement in FAAM scores (T0: 71%, T2: 95%) and pain reduction (VAS: T0: 7.67, T2: 1.00). Two-anchor repairs yielded superior outcomes compared to single-anchor procedures (p = 0.01). While higher BMI was associated with poorer outcomes (p = 0.04), internal bracing improved functional scores in this subgroup. Preoperative FAAM scores did not predict postoperative outcomes (p = 0.21).
All-inside arthroscopic ligament repair is a safe and effective option for CAI, providing rapid recovery, low complication rates, and excellent patient satisfaction.
Level IV.
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