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Mahmut Nedim Doral, Onur Bilge, Gazi Huri, Egemen Turhan, and René Verdonk

  • The complex ultrastructure of the meniscus determines its vital functions for the knee, the lower extremity, and the body.

  • The most recent concise, reliable, and valid classification system for meniscal tears is the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Classification, which takes into account the subsequent parameters: tear depth, tear pattern, tear length, tear location/rim width, radial location, location according to the popliteal hiatus, and quality of the meniscal tissue.

  • It is the orthopaedic surgeon’s responsibility to combine clinical information, radiological images, and clinical experience in an effort to individualize management of meniscal tears, taking into account factors related to the patient and lesion.

  • Surgeons should strive not to operate in most cases, but to protect, repair or reconstruct, in order to prevent early development of osteoarthritis by restoring the native structure, function, and biomechanics of the meniscus.

  • Currently, there are three main methods of modern surgical management of meniscus tears: arthroscopic partial meniscectomy; meniscal repair with or without augmentation techniques; and meniscal reconstruction. Meniscus surgery has come a long way from the old slogan, “If it is torn, take it out!” to the currently accepted slogan, “Save the meniscus!” which has guided evolving modern treatment methods for meniscal tears. This last slogan will probably constitute the basis for newer alternative biological treatment methods in the future.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170067.

Francisco Figueroa, David Figueroa, and João Espregueira-Mendes

  • Graft size in hamstring autograft anterior cruciate ligament (ACL) surgery is an important factor directly related to failure. Most of the evidence in the field suggests that the size of the graft in hamstring autograft ACL reconstruction matters when the surgeon is trying to avoid failures.

  • The exact graft diameter needed to avoid failures is not absolutely clear and could depend on other factors, but newer studies suggest than even increases of 0.5 mm up to a graft size of 10 mm are beneficial for the patient. There is still no evidence to recommend the use of grafts > 10 mm.

  • Several methods – e.g. folding the graft in more strands – that are simple and reproducible have been published lately to address the problem of having an insufficient graft size when performing an ACL reconstruction. Due to the evidence presented, we think it is necessary for the surgeon to have them in his or her arsenal before performing an ACL reconstruction.

  • There are obviously other factors that should be considered, especially age. Therefore, a larger graft size should not be taken as the only goal in ACL reconstruction.

Cite this article: EFORT Open Rev 2018;3:93-97. DOI: 10.1302/2058-5241.3.170038

Louis Dagneaux, Julien Bourlez, Benjamin Degeorge, and François Canovas

  • Knee arthroplasty survival rate — either UKA or TKA — is currently 95%, greater than it was ten years ago, but has not been specifically evaluated in very active patients practicing sport at a high intensity.

  • The terms and conditions of return to physical activities are decided by the surgeon, the rehabilitation or Sports Medicine doctor, who needs to make sure that postoperative rehabilitation has been conducted optimally. Specifically, range of movement must be complete, muscular strengthening has to be sufficient and balance must be recovered by proprioception. Only after this stage (i.e. three to six months after surgery) can physical activities be resumed.

  • Return to sport must be gentle and progressive, with moderate activities limited to short sessions. Progressively the patient will be able to return to intermediate activities, provided that he/she possesses the adequate level of technique for the sport.

  • This up-to-date review for young surgeons and residents aims to provide an informative guide for patients regarding sport following knee arthroplasty.

Cite this article: EFORT Open Rev 2017;2:496–501. DOI: 10.1302/2058-5241.2.170037

Michele Boffano, Stefano Mortera, Hazem Wafa, and Raimondo Piana

  • Acromioclavicular joint (ACJ) injuries are common, but their incidence is probably underestimated. As the treatment of some sub-types is still debated, we reviewed the available literature to obtain an overview of current management.

  • We analysed the literature using the PubMed search engine.

  • There is consensus on the treatment of Rockwood type I and type II lesions and for high-grade injuries of types IV, V and VI. The treatment of type III injuries remains controversial, as none of the studies has proven a significant benefit of one procedure when compared with another.

  • Several approaches can be considered in reaching a valid solution for treating ACJ lesions. The final outcome is affected by both vertical and horizontal post-operative ACJ stability. Synthetic devices, positioned using early open or arthroscopic procedures, are the main choice for young people.

  • Type III injuries should be managed surgically only in cases with high-demand sporting or working activities.

Cite this article: EFORT Open Rev 2017;2:432–437. DOI: 10.1302/2058-5241.2.160085.

Mohammad Shahid and Rik Kundra

  • Platelet-rich plasma (PRP) is an autologous blood product with platelet concentrations above baseline values. The process involves the extraction of blood from the patient which is then centrifuged to obtain a concentrated suspension of platelets by plasmapheresis. It then undergoes a two-stage centrifugation process to separate the solid and liquid components of the anticoagulated blood. PRP owes its therapeutic use to the growth factors released by the platelets which are claimed to possess multiple regenerative properties.

  • In the knee, PRP has been used in patients with articular cartilage pathology, ligamentous and meniscal injuries.

  • There is a growing body of evidence to support its use in selected indications and this review looks at the most recent evidence. We also look at the current UK National Institute of Health & Clinical Excellence (NICE) guidelines with respect to osteoarthritis and the use of PRP in the knee.

Cite this article: EFORT Open Rev 2017;2:28–34. DOI: 10.1302/2058-5241.2.160004.

Nikolaos K. Paschos and Stephen M. Howell

  • Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients.

  • This instructional review discusses the principles of ACL reconstruction in an attempt to provide guidelines and initiate a critical thinking approach on the most common areas of controversy regarding ACL reconstruction.

  • Using high-level evidence from the literature, as presented in randomised controlled trials, systematic reviews, and meta-analyses, operative versus conservative treatment, timing of surgery, and rehabilitation are discussed. Also, the advantages and disadvantages of the most common types of autografts, such as patellar tendon and hamstrings as well as allografts are presented.

  • Key considerations for the anatomical, histological, biomechanical and clinical data (‘IDEAL’) graft positioning are reviewed.

Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032.

N. Reha Tandogan and Asim Kayaalp

  • The medial collateral ligament (MCL) and the posterior oblique ligament (POL) are the main static valgus restraints of the knee.

  • Most isolated medial injuries can be treated with bracing and early knee motion.

  • Combined MCL and ACL (anterior cruciate ligament) injuries can be managed with bracing of the knee followed by a delayed reconstruction of the ACL.

  • Residual medial laxity may be addressed at the time of ACL surgery.

  • Bony avulsions, incarceration of the distal MCL under the meniscus or over the pes anserinus tendons, open injuries, MCL tears combined with PCL or bi-cruciate injuries should be treated surgically.

  • Chronic symptomatic medial instability can be managed with the recently described reconstruction techniques using free tendon grafts located at anatomical insertion sites.

Cite this article: Tandogan NR, Kayaalp A. Surgical treatment of medial knee ligament injuries: Current indications and techniques. EFORT Open Rev 2016;2:27-33. DOI: 10.1302/2058-5241.1.000007.