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Surgical Techniques & Trauma

Management of tibial plateau fractures, focusing on Schatzker V and VI bicondylar patterns and the balance between articular restoration and soft tissue preservation.

Overview

Effective orthopaedic trauma management requires surgeons to master common fracture types, evaluation methods, treatment options, and expected complications to prevent adverse outcomes [1]. Understanding current evidence and appropriate indications for emerging technologies is critical for their successful utilization [22]. While specific techniques such as the arthroscopic inside-out approach for knee posterolateral portal development are simple, reproducible, and free of major complications in large cohorts [5], and hardware-free MPFL reconstruction with intra-operative tension adjustment offers effective stabilization with low complication rates and high patient satisfaction [15], broader research is still required to define long-term outcomes for combined anterior cruciate ligament reconstruction with articular cartilage injury [2].

Surgical indications vary by pathology, with surgery generally indicated for complete extensor mechanism tendon ruptures [16]. For patellofemoral disorders, the prone position for minimal invasive or all-arthroscopic autologous chondrocyte implantation reduces surgical trauma [6], while radiofrequency energy for arthroscopic chondroplasty should be used cautiously given the low quality of clinical evidence regarding its safety and efficacy [4]. Similarly, prospective investigation is warranted to better describe long-term outcomes using radial plate fixation for distal radius fractures [10], and larger clinical outcome studies are needed to ensure the efficacy and safety of hardware-free MPFL reconstruction techniques [15].

Patient selection and monitoring remain paramount in complex scenarios. Stringent criteria must be followed for guided growth in correcting knee deformity in patients with congenital insensitivity to pain, with close follow-up required to prevent complications [62]. Individual surgeon thresholds for decompression in arthroscopic acromioplasty remain varied and non-standardized [23], whereas all-inside suture anchor repair for meniscal root tears is encouraged based on experience yielding good results without complication [25].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Restoration of knee kinematics is central to reconstruction strategies, though the efficacy of specific techniques remains debated. While both fixation protocols in double-bundle anterior cruciate ligament (ACL) reconstruction restored knee kinematics without predisposing either graft to failure [29], and both three-tunnel double-bundle ACL reconstructions performed anatomically demonstrated similar biomechanical behavior [60], the effective role of the anatomical double-bundle procedure in better restoring knee kinematics and allowing better clinical outcomes should be questioned in an in vivo model [30, 35]. Abnormal tensile behavior occurred in anatomically placed tibial tunnels but was compatible with a stable and functional reconstructed knee at 1 year [39]. Conversely, the knot/press-fit technique restores knee kinematics as well as the EndoButton CL fixation and has similar biomechanical properties as other devices published in the literature [46].

In posterior cruciate ligament (PCL) reconstruction, a novel arthroscopic double bundle U-DOS reverse technique aims to reconstruct the ligament closely to its normal anatomy by mimicking the anterolateral and posteromedial bundles, which significantly improves knee stability and kinematics [67]. Regarding total knee arthroplasty (TKA), joint gap kinematics was inconsistent within four different surgical approaches and two different patellar positions in posterior-stabilized TKA [40], while patellofemoral kinematics and retropatellar pressure change after TKA in different manners depending on the type of TKA used [49]. Intraoperative kinematics was excellent in terms of gap-force balancing and femorotibial relative motion in robotic-assisted differential TKA with patient-specific implants [64], yet discrepancies occurred in midflexion when evaluating robotic-assisted functional positioning in varus knees across flexion and extension with quantitative sensor-guided technology [59].

Osseous Alignment and Tunnel Geometry

Realignment osteotomy around the knee is primarily used to correct biomechanical abnormalities and asymmetric loading across the knee joint due to malalignment [31]. Surgical approach and tunnel geometry significantly influence graft mechanics; a shallower knee flexion angle (less than 80°) during femoral tunnel creation using the modified transtibial technique provided a gentler femoral graft bending angle compared to 80° or more of knee flexion [63]. Increasing posterior tibial slope in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads [48].

Graft Biomechanics and Tensioning

A successful graft tensioning strategy requires understanding native anatomy, ligament biomechanics, graft mechanical properties, fixation methods, and the specific biomechanical goals of the reconstruction [58]. Increased pretension combined with changes in graft excursion produces dramatic increases in graft force when the knee is flexed to 90°, which could be detrimental to a remodeling graft and lead to subsequent failure of the reconstruction [66]. Biomechanical research has not provided satisfactory evidence as to the benefits of tunnel dilation during anterior cruciate ligament reconstruction [65].

Clinical Assessment and Pathology

Non-anatomical capsular closure of a standard parapatellar knee arthrotomy leads to patellar maltracking and decreased range of motion [52]. Mechanical interactions with other players impact segmental kinematics before and during anterior cruciate ligament injuries in professional male football players [53]. A noninvasive device is a useful and valuable tool to investigate preoperative and postoperative influences on tibiofemoral rotation and provides additional objective information on knee kinematics in a simple, reproducible manner [54].

Classification

General Principles: Surgeons must understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [1]. Employing individualized classification systems remains the most logical approach for tibial plateau fractures [50]. A classification system for tibial plateau fractures based on injury mechanism and morphological characteristics has instructive significance for preoperative evaluation of fracture features and soft tissue problems [12]. Further research is needed to validate the reliability of mechanism-associated 3-dimensional tibial plateau fracture pattern classifications among surgeons and to determine their value in diagnosis and surgical protocol formulation [14]. Geriatric tibial plateau fractures have a unique distribution in classification [70].

Floating Knee: A digital classification system of floating knee injury based on AO classification can classify most cases of floating knee injury and cases with open injury, serving as an effective reference for selecting surgical treatment plans [51].

Osteoarthritis: Six radiographic osteoarthritis classification systems demonstrated moderate interobserver reliability for anteroposterior radiographs and good interobserver reliability for 45° posteroanterior flexion weight-bearing radiographs [75]. These six radiographic osteoarthritis classification systems demonstrated medium correlation with arthroscopic findings [75].

Other Considerations: Risk Stratification: Management of overuse injuries is stratified by risk, with high-risk fractures requiring aggressive treatment such as absolute rest or surgery [24]. Low-risk fractures typically heal with activity modification [24]. Surgical Planning & Outcomes: A specific treatment protocol can help determine the surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries [79]. Generic statements regarding tunnel placement in anatomic single-bundle anterior cruciate ligament reconstruction should no longer be used in modern literature [72]. Additional studies are needed to better define the incidence of combined anterior cruciate ligament reconstruction and articular cartilage injury and the long-term outcomes after these procedures [2]. The quality of clinical evidence regarding the safety and efficacy of radiofrequency energy for arthroscopic chondroplasty in the knee remains low, despite few reported complications [4]. The arthroscopic inside-out technique for knee posterolateral portal development is simple, reproducible, and demonstrated safety with no major complications in a large cohort [5]. The prone position for minimal invasive or all-arthroscopic autologous chondrocyte implantation at the patella reduces surgical trauma for the patient [6].

Clinical Presentation

Surgeons must understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [1]. Accurate diagnosis and individualized treatment plans for knee ligamentous injuries are emphasized based on patient activity level and injury severity [38]. A comprehensive overview of ligamentous injuries of the knee includes epidemiology, pathoanatomy, evaluation, and treatment of ACL, MCL, LCL, and PCL injuries [38].

Fracture Evaluation and Classification

A classification system based on injury mechanism and morphological characteristics of tibial plateau fractures has instructive significance for preoperative evaluation of fracture features and soft tissue problems [12]. The proposed classification system for tibial plateau fractures guides clinical management for better functional outcomes [12]. Further research is needed to validate the reliability of mechanism-associated 3-dimensional tibial plateau fracture pattern classifications among surgeons and to determine their value in diagnosis and surgical protocol formulation [14]. Traumatic proximal tibiofibular dislocation is a rare injury often unrecognized or misdiagnosed at initial presentation [28]. When diagnosed, traumatic proximal tibiofibular dislocation should be promptly reduced to avoid chronic morbidity [28].

Ligamentous and Soft Tissue Assessment

There is a paucity of literature focused on the management of combined anterior cruciate ligament and posterolateral corner tears [17]. A lesion-specific 20-item checklist for surgical planning in acute multiligament knee trauma clearly defines the surgical protocol, facilitates preparations for surgery, and is associated with favorable midterm outcomes [32]. An arthroscopic technique to treat iliotibial band syndrome allows for the exclusion and treatment of other intra-articular pathology [18]. A new algorithm for rotational instability treatment in individualized ACL reconstruction accounts for patients' unique anatomical characteristics and objective measurement of the pivot shift sign [34].

Special Populations and Outcomes

In a series of adolescent patellar osteochondral fractures following patellar dislocation, patients without fixation were less symptomatic, which may be attributable to more severe injuries in patients undergoing fracture fixation [13]. A two-stage silicone tube and interposition hamstring tendons graft protocol provides a very good functional outcome for complicated traumatic tibialis anterior tendon ruptures in young adults, even when delayed repairs are complicated by infection [3]. Meeting clinically pain-free criteria during criteria-based rehabilitation of acute adductor injuries in male athletes results in fewer reinjuries compared with not meeting the criteria [19].

Procedural Considerations and Gaps

The use of radiofrequency energy for arthroscopic chondroplasty in the knee requires cautious and judicious application until future research defines long-term clinical outcomes and risks [4]. Reported complications from radiofrequency energy for arthroscopic chondroplasty in the knee are few, but the quality of clinical evidence regarding safety and efficacy remains low [4]. Safe and reproducible knee posterolateral portal development using an arthroscopic inside-out technique is simple, reproducible, and demonstrated free of major complications in a large cohort [5]. The prone position for minimal invasive or all-arthroscopic autologous chondrocyte implantation at the patella reduces surgical trauma for the patient [6]. A learning curve cutoff of 30 cases for hip arthroscopy is associated with significant reductions in operative time and complication rates [9].

Unresolved Clinical Questions

Additional studies are needed to better define the incidence of combined anterior cruciate ligament reconstruction and articular cartilage injury and the long-term outcomes after these procedures [2]. There is an urgent need to establish the risk factors associated with quadriceps tendon rupture [33]. There is an urgent need to establish the optimal surgical technique for quadriceps tendon rupture [33]. The literature review confirmed a paucity of evidence to guide clinicians in the diagnosis and surgical management of increased posterior tibial slope in revision anterior cruciate ligament surgery [27].

Investigations

Plain radiography: Surgeons must understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [1]. A simple radiographic assessment of femoral tunnel placement expressed as intercondylar clock time in double-bundle anterior cruciate ligament reconstruction is reproducible, reliable for clinical use, and useful for evaluating ACL reconstructive procedures [69]. Preoperative CT imaging shift parameters of the lateral plateau may provide novel reference metrics for the early diagnosis of lateral meniscal injury when MRI is not available in Schatzker IV-C tibial plateau fractures [73].

MRI: Magnetic resonance imaging may allow early prediction of lesion healing potential in osteochondritis dissecans of the knee [61]. MRI offers only a marginal benefit for diagnosing meniscal injuries in patients with split-depression fractures of the lateral tibial condyle due to poor specificity and sensitivity [68]. All-inside meniscocapsular tear repair is successful clinically, functionally, and in respect of MRI findings [71]. A randomized controlled trial design exists to compare MRI-derived signal intensity of ACL grafts one year after transtibial versus anteromedial portal techniques, hypothesizing that the anteromedial portal technique will result in better graft maturity [88].

CT: CT imaging is recommended for precise evaluation of femoral tunnel position in ACL reconstruction, particularly in failed reconstructions requiring revision, comparative studies, or second opinions [47].

Other Considerations: Additional studies are needed to better define the incidence of combined anterior cruciate ligament reconstruction and articular cartilage injury and the long-term outcome after these procedures [2]. A two-stage silicone tube and interposition hamstring tendons graft protocol provides a very good functional outcome for complicated cases in young adults, including delayed tendon repairs complicated by infection [3]. Concurrent medial meniscal posterior root repair during proximal tibial osteotomy does not significantly improve clinical and radiologic outcomes at short-term follow-up [7]. Minimally invasive double level osteotomy restores physiologic knee joint alignment and orientation in osteoarthritic knees with severe varus deformity, supported by excellent clinical and radiological outcomes despite a short follow-up period [11]. An arthroscopic technique for iliotibial band syndrome allows for the exclusion and treatment of other intra-articular pathology [18]. Meeting clinically pain-free criteria during criteria-based rehabilitation of acute adductor injuries in male athletes results in fewer reinjuries compared with not meeting the criteria [19]. Patient-specific instrumentation for total knee arthroplasty does not match the pre-operative plan as assessed by intra-operative computer-assisted navigation [74]. Patient-specific instrumentation devices for total knee arthroplasty should not be used without objective verification of alignment, either in real-time or with post-operative imaging [74]. Clinical and radiological outcomes between navigation-assisted gap balancing and conventional measured resection for soft tissue balancing in total knee arthroplasty are similar [77]. No significant differences were found between two arthroscopic rotator cuff repair techniques in terms of functional and radiological results [80]. Physeal sparing arthroscopic fixation of displaced tibial eminence fractures showed excellent to good clinical and radiological results and may be a physeal sparing alternative to previously described procedures [85].

Treatment

Non-Operative

Non-surgical management is successful for low-risk fractures, which typically heal with activity modification [24]. In specific cases such as avascular necrosis of the sesamoid bone, non-surgical management has proven successful with no further treatment necessary [55]. For posterior cruciate ligament (PCL) avulsion fractures, the amount of displacement can determine the appropriateness of non-operative treatment, with outcomes comparable to those of patients with acute isolated PCL injuries [76].

Operative

Indications: Surgery is generally indicated for complete tendon rupture [16]. Surgical management of patellar dislocation is associated with a lower rate of re-dislocation compared to conservative management, though it remains unclear whether surgery produces greater functional outcomes [82]. For stable juvenile osteochondritis dissecans (OCD) lesions that fail to heal after 3–6 months of non-operative treatment, retro-articular drilling and bone grafting represents a promising adjunct [78].

Surgical Approach / Technique: A two-stage silicone tube and interposition hamstring tendon graft protocol should be considered for complicated cases in young adults, providing very good functional outcomes even in delayed tendon repairs complicated by infection [3]. The arthroscopic inside-out technique for knee posterolateral portal development is simple, reproducible, and demonstrated safety with no major complications in a large cohort [5]. The prone position for minimal invasive or all-arthroscopic autologous chondrocyte implantation at the patella is minimal invasive and reduces surgical trauma for the patient [6]. Combined arthroscopic treatment of tibial plateau and intercondylar eminence avulsion fractures allows for anatomic joint reconstruction with minimally invasive techniques and offers advantages in surgical morbidity, hospital stay, and recovery [42]. Paediatric proximal ACL tears managed with direct ACL repair are safe, effective, and have excellent short-term outcomes [44].

Implant Selection: Plate osteosynthesis is an alternative method for treating symptomatic non-unions of the base of the ulnar styloid that provides stable fixation with low risk of implant removal [81]. A hardware-free MPFL reconstruction technique with intra-operative adjustment of graft tension provides good clinical outcomes, high satisfaction, and a low incidence of complications [15]. One-incision and two-incision techniques for anterior cruciate ligament reconstruction with patellar tendon graft are comparable in terms of stability and functional outcome at short-term follow-up [8]. For most repairable meniscal tears, the optimal minimal penetration depth for all-inside repairs may be as short as 8 mm and is not likely to be greater than 16 mm [86].

Alignment / Balancing Strategy: Concurrent medial meniscal posterior root repair during proximal tibial osteotomy does not significantly improve clinical and radiologic outcomes at short-term follow-up [7].

Pain Management: Reported complications from radiofrequency energy for arthroscopic chondroplasty are few, but the quality of clinical evidence regarding safety and efficacy remains low [4]. Radiofrequency energy for arthroscopic chondroplasty should be used cautiously and judiciously until future research defines long-term clinical outcomes and risks [4].

Adjuncts: Positive outcomes for meniscal allograft transplantation are most likely to be achieved when performed in appropriately selected patients, with studies reporting long-term graft survivorship as high as 89% at 10 years [43]. Meniscal allograft transplantation results in significant improvements in multiple patient reported outcome measures [43]. Functional outcome in meniscal repair does not depend on the repair technique, whether using an all-inside suture device or meniscal arrows [20].

Other Considerations: Surgeons must understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [1]. There is a paucity of literature focused on the management of combined anterior cruciate ligament and posterolateral corner injuries [17]. Management of overuse injuries is stratified by risk, with high-risk fractures requiring aggressive treatment such as absolute rest or surgery [24]. Individual surgeon thresholds for the need and adequacy of decompression in arthroscopic acromioplasty are varied and not standardized [23]. Understanding current evidence and appropriate indications for emerging technologies in orthopaedic trauma is of critical importance for their utilization [22]. Work remains to maximize the effectiveness of surgical simulation in fracture treatment through improved model integration and access [45]. A larger clinical outcome study is needed to ensure the efficacy and safety of the hardware-free MPFL reconstruction technique with intra-operative graft tension adjustment [15].

Complications

General Surgical Outcomes: Surgeons must understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [1]. Significant reductions in operative time and complication rates occur after a surgeon completes 30 cases of hip arthroscopy [9]. Concurrent medial meniscal posterior root repair during proximal tibial osteotomy does not significantly improve clinical and radiologic outcomes at short-term follow-up [7]. One-incision and two-incision techniques for anterior cruciate ligament reconstruction with patellar tendon graft are comparable in terms of stability and functional outcome at short-term follow-up [8].

Infection (PJI): A two-stage silicone tube and interposition hamstring tendons graft protocol provides a very good functional outcome even in delayed tendon repairs complicated by infection [3].

Instability: Results for proximal anterior cruciate ligament avulsion fracture repair in skeletally immature athletes are encouraging at short-term follow-up [21]. A novel arthroscopic technique for fixation of tibial spine avulsion fractures leads to satisfactory clinical evolution of patients [84]. In a series of adolescent patellar osteochondral fractures following patellar dislocation, patients without fixation were less symptomatic, which may be attributable to more severe injuries in patients undergoing fracture fixation [13].

Wound complications: Pain requiring hardware removal was the most common complication in both closing wedge and opening wedge distal femoral osteotomy techniques [41].

Other Considerations: Additional studies are needed to better define the incidence of combined anterior cruciate ligament reconstruction and articular cartilage injury and the long-term outcomes after these procedures [2]. The use of radiofrequency energy for arthroscopic chondroplasty requires cautious and judicious application until future research defines long-term clinical outcomes and risks [4], as reported complications are few but the quality of clinical evidence regarding safety and efficacy remains low [4]. A large cohort using an arthroscopic inside-out technique for knee posterolateral portal development was free of major complications [5]. Further prospective investigation is warranted to better describe long-term outcomes of radial plate fixation for distal radius fractures [10]. The follow-up period for minimally invasive double level osteotomy for osteoarthritic knees with severe varus deformity is still short [11]. All-inside suture anchor repair for meniscal root tears has yielded good results without complication in the authors' experience [25]. The rate of complications for high tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion was low [26], with approximately two-thirds of knees treated with high tibial osteotomy having a good or excellent clinical result at an average of 8.5 years [26]. Long-term survivability of distal femoral osteotomy is a function of follow-up duration and not surgical technique [41]. Simultaneous acute femoral deformity correction and gradual limb lengthening using a retrograde femoral nail may help avoid complications associated with prolonged postoperative use of an external fixator [83]. The majority of studies on anterior cruciate ligament allograft surgery do not accurately report key elements of graft history including tissue bank, processing or sterilization technique, or donor age [87].

Recovery

Light activity (weeks): Specific timelines for light activity are not explicitly defined in the provided evidence; however, early motion is noted as a component of successful high tibial osteotomy protocols [26], and early functional outcomes after subvastus or parapatellar approaches in knee arthroplasty are comparable with no functional difference existing after 6 months [56].

Full activity (months): Functional outcomes for meniscal repair do not depend on the repair technique, whether using an all-inside suture device or meniscal arrows [20]. One-incision and two-incision techniques for anterior cruciate ligament reconstruction with patellar tendon graft are comparable in terms of stability and functional outcome at short-term follow-up [8]. Results for proximal anterior cruciate ligament avulsion fracture repair in skeletally immature athletes are encouraging at short-term follow-up [21]. A two-stage silicone tube and interposition hamstring tendons graft protocol provides a very good functional outcome for complicated traumatic tibialis anterior tendon ruptures in young adults, even in delayed repairs complicated by infection [3]. Minimally invasive double level osteotomy restores physiologic knee joint alignment and orientation in osteoarthritic knees with severe varus deformity, with excellent clinical and radiological outcomes despite a short follow-up period [11]. High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion resulted in a low complication rate and approximately two-thirds of knees having a good or excellent clinical result at an average of 8.5 years [26]. Patients with a preoperative symptom duration of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes compared to patients with a symptom duration of less than 2 years after high tibial osteotomy at mid-term follow-up [91].

Complete recovery / outcome plateau (months): Concurrent meniscal root repair during proximal tibial osteotomy does not significantly improve clinical and radiologic outcomes at short-term follow-up [7]. Further prospective investigation is warranted to better describe long-term outcomes using radial plate fixation for distal radius fractures [10]. Potential benefits of computer-assisted total knee arthroplasty versus conventional technique in long-term outcome and functional improvement require further investigation [37]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis for focal cartilage defects will maintain structural and functional integrity over time [57]. Additional studies are needed to better define the incidence of combined anterior cruciate ligament reconstruction and articular cartilage injury and the long-term outcome after these procedures [2].

Rehabilitation protocol: A shortened immobilization protocol yields less favorable results than expected for extensor mechanism reconstruction with Achilles tendon allograft in total knee arthroplasty [90]. Continuous monitoring of patients who had allograft reconstruction for extensor mechanism in total knee arthroplasty is recommended for possible development of late infection [90].

Functional milestones: Predictors of superior functional outcome after corrective osteotomy for malunited paediatric forearm fractures include an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20°, and the use of three-dimensional computer-assisted techniques [92]. Surgical time decreases as a surgeon advances through the learning curve in hip arthroscopy, with the initial 75 procedures requiring longer time to perform than subsequent cases [89]. Using 30 cases as a cutoff point to differentiate between early and late cases in a surgeon's experience for hip arthroscopy results in significant reductions in operative time and complication rates [9]. There is a notable linear decrease in surgical time and the number of cases completed without associated detriment to postoperative outcomes as surgeons advance through the learning curve in arthroscopically assisted lower trapezius transfer [93].

Other Considerations: No specific evidence regarding return-to-work failure predictors or patient-selection caveats for early ROM was found in the provided L1 data beyond the general learning curve observations and infection monitoring recommendations.

Key Evidence

  • [L4] Additional studies are needed to better define both the incidence of combined injury and the outcome, particularly in the long term, after these procedures. (10.1016/j.arthro.2009.09.002)
  • [L4] This method should be considered for the treatment of complicated cases in young adults, as it provides a very good functional outcome even in delayed tendon repairs complicated by infection. (10.1007/s00167-013-2544-6)
  • [L5] Although reported complications are few, the quality of clinical evidence about safety and efficacy remains low; the authors suggest cautious and judicious use of this technology until future research has clearly defined the long-term clinical outcomes and risks. (10.1016/j.arthro.2010.11.058)
  • [L4] The technique is simple, reproducible, and the current large cohort being free of major complications demonstrates its safety. (10.1016/j.jisako.2025.101057)
  • [L4] The technique is minimal invasive and does reduce the surgical trauma for the patient. (10.1007/s00167-011-1505-1)
  • [L3] However, concurrent repair does not significantly improve clinical and radiologic outcomes at short-term follow-up. (10.1016/j.arthro.2020.04.038)
  • [L1] Both techniques are comparable in terms of stability and functional outcome at short-term follow-up. (10.1007/s001670050052)
  • [L4] When 30 cases was used as the cutoff point to differentiate between early and late cases in a surgeon's experience, there were significant reductions in operative time and complication rates. (10.1016/j.arthro.2013.11.012)
  • [L4] Further prospective investigation is warranted to better describe long-term outcomes using this technique. (10.1177/1558944716669136)
  • [L4] Although the follow-up period is still short, the excellent clinical and radiological outcomes shown in the present study support the efficacy of this procedure. (10.1007/s00167-018-5103-3)
  • [L4] The proposed classification system based on injury mechanism and morphological characteristics has instructive significance for preoperative evaluation of fracture features and soft tissue problems, and guides clinical management for better functional outcomes. (10.1186/s13018-019-1321-8)
  • [L4] While patients without fixation were less symptomatic in this series, this may be attributable to more severe injuries in patients undergoing fracture fixation. (10.1007/s00167-012-2179-z)
  • [L4] Further research is needed to validate the classification reliability among other surgeons and to determine the potential value in the diagnosis and formulation of surgical protocols. (10.2106/jbjs.19.00485)
  • [L4] The study suggests the technique provides good clinical outcomes, high satisfaction, and a low incidence of complications, though a larger clinical outcome study is needed to ensure efficacy and safety. (10.1007/s00167-017-4723-3)
  • [L4] There is a paucity of literature focused on the management of combined ACL and PLC injuries. (10.1177/0363546513507555)
  • [L4] The approach also allows for the exclusion and treatment of other intra-articular pathology. (10.1007/s00167-008-0660-5)
  • [L2] Meeting the clinically pain-free criteria resulted in fewer reinjuries compared with not meeting the criteria. (10.1177/2325967119897247)
  • [L1] Functional outcome did not depend on the repair technique. (10.1007/s00167-014-3423-5)
  • [Case_report] At short-term follow-up the results are encouraging. (10.1007/s00167-006-0154-2)
  • [L5] Individual surgeon thresholds for the need and adequacy of decompression are varied and are not standardized. (10.1016/j.arthro.2016.01.010)
  • [L4] The authors encourage surgeons to consider this technique, noting their experience has yielded good results without complication. (10.1007/s00167-009-0743-y)
  • [L4] In this series, the rate of complications was low and approximately two-thirds of the knees had a good or excellent clinical result at an average of 8.5 years. (10.2106/00004623-200001000-00009)
  • [L5] The literature review confirmed a paucity of evidence to guide clinicians in the diagnosis and surgical management of increased PTS. (10.1016/j.jisako.2025.100900)
  • [L5] Traumatic proximal tibiofibular dislocation is a rare injury often unrecognized or misdiagnosed at initial presentation; when diagnosed, the injury should be promptly reduced to avoid chronic morbidity. (10.1177/0363546507312162)
  • [L5] Both fixation protocols restored knee kinematics without predisposing either graft to failure. (10.1177/0363546507300822)
  • [L4] The effective role of the anatomical double-bundle procedure in better restoring knee kinematics should be questioned in an in vivo model. (10.1177/0363546507305677)
  • [L5] Realignment osteotomy around the knee is primarily used to correct biomechanical abnormalities and asymmetric loading across the knee joint due to malalignment. (10.1016/j.arth.2024.10.065)
  • [L4] A lesion-specific 20-item checklist designed for surgical planning in acute multiligament knee trauma clearly defines the surgical protocol, facilitates preparations for surgery, and is associated with favorable midterm outcomes. (10.1016/j.jisako.2025.101064)
  • [L4] There is an urgent need to establish the risk factors associated with quadriceps tendon rupture and to also establish the optimal surgical technique. (10.1007/s00167-019-05453-y)
  • [L5] A new algorithm for rotational instability treatment is presented, accounting for patients' unique anatomical characteristics and objective measurement of the pivot shift sign allowing for an individualized surgical treatment. (10.1007/s00167-014-2928-2)
  • [L4] The effective role of the anatomical double-bundle procedure in better restoring knee kinematics and allowing better clinical outcomes should be questioned in an in vivo model. (10.1177/0363546509339021)
  • [L4] This standard operating procedure is expected to help achieve favorable outcomes and can be used to treat various pathologies leading to TSS. (10.1186/s13018-020-01838-9)
  • [L2] Potential benefits in long-term outcome and functional improvement require further investigation. (10.1007/s00167-007-0399-4)
  • [L3] Abnormal tensile behavior occurred in anatomically placed tibial tunnels and was compatible with a stable and functional reconstructed knee at 1 year. (10.1177/03635465990270030301)
  • [L2] Joint gap kinematics was inconsistent within four different approaches and two different patellar positions. (10.1007/s00167-011-1813-5)
  • [L4] Pain requiring hardware removal was the most common complication in both techniques, while long-term survivability was found to be a function of follow-up and not surgical technique. (10.1177/03635465211051740)
  • [L4] Combined arthroscopic treatment allows for anatomic joint reconstruction with minimally invasive techniques, offering advantages in surgical morbidity, hospital stay, and recovery. (10.2106/jbjs.j.00812)
  • [L5] Positive outcomes for meniscal allograft transplantation are most likely to be achieved when performed in appropriately selected patients, with studies reporting long-term graft survivorship as high as 89% at 10 years and significant improvements in multiple patient reported outcome measures. (10.1007/s00167-020-06058-6)
  • [L4] Our results demonstrate that paediatric ACL repair is safe and effective. (10.1007/s00167-020-05872-2)
  • [L5] Work remains to maximize the effectiveness of surgical simulation in fracture treatment through improved model integration and access. (10.5435/jaaos-d-20-00076)
  • [L5] The knot/press-fit technique restores knee kinematics as well as the EndoButton CL fixation and has similar biomechanical properties as other devices published in the literature. (10.1177/0363546504271745)
  • [L3] CT imaging is recommended for precise evaluation, particularly in failed reconstructions requiring revision, comparative studies, or second opinions. (10.1007/s00167-004-0548-y)
  • [L5] Increasing PTS in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads. (10.1002/ksa.12577)
  • [L5] Patellofemoral kinematics and retropatellar pressure change after TKA in different manners depending on the type of TKA used. (10.1007/s00167-017-4772-7)
  • [L2] Therefore, employing individualized classification systems remains the most logical approach at present. (10.1530/eor-2024-0184)
  • [L4] The digital classification system of floating knee injury based on AO classification could classify most cases of floating knee injury and cases with open injury, which referred to a reference effectively for the selection of surgical treatment plan, and would be conducive to the future clinical classification. (10.1186/s12891-024-08078-6)
  • [L5] Therefore, every effort should be made to provide anatomical closure of the extensor mechanism to preserve native patellar movement kinematics. (10.1007/s00167-013-2369-3)
  • [L4] Mechanical interactions with other players impact segmental kinematics before and during ACL injuries in professional male football. (10.1002/ksa.12612)
  • [Letter] The authors conclude that while the introduced noninvasive device has limitations, it is a useful and valuable tool to investigate preoperative and postoperative influences on tibiofemoral rotation and provides additional objective information on knee kinematics in a simple, reproducible manner. (10.1177/0363546510376622)
  • [L4] Non-surgical management was successful in this case of avascular necrosis of the sesamoid bone, with no further treatment necessary. (10.1177/1753193408094153)
  • [L5] The authors agree with Maffulli et al. that more work is needed on long-term effects, but maintain their paper was intended to study early postoperative differences where no functional difference exists after 6 months. (10.1007/s00167-011-1815-3)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L5] A successful strategy requires understanding native anatomy, ligament biomechanics, graft mechanical properties, fixation methods, and the specific biomechanical goals of the reconstruction. (10.5435/jaaos-20-10-633)
  • [L2] Nevertheless, some discrepancies occurred in midflexion, and more work is needed to understand ligament behaviour all along the arc of knee flexion. (10.1002/ksa.12255)
  • [L5] Both three-tunnel DB ACL reconstructions performed in an anatomic fashion had similar biomechanical behavior. (10.1007/s00167-010-1338-3)
  • [L5] Magnetic resonance imaging may allow early prediction of lesion healing potential, and arthroscopic drilling is recommended for skeletally immature patients with stable lesions that have not healed with nonoperative treatment. (10.1177/0363546506290127)
  • [L4] Patients should be closely followed to prevent complications, and stringent patient selection criteria should be followed to ensure success. (10.1186/s13018-021-02304-w)
  • [L3] Shallower flexion angle (less than 80°) provided gentler femoral graft bending angle compared to 80° or more of knee flexion. (10.1007/s00167-018-5191-0)
  • [L4] Intraoperative kinematics was excellent in terms of gap-force balancing and femoraltibial relative motion. (10.1186/s42836-024-00255-1)
  • [L5] Biomechanical research has not provided satisfactory evidence as to the benefits of this additional surgical step during anterior cruciate ligament reconstruction. (10.1007/s001670100212)
  • [L5] This increased pretension, combined with changes in graft excursion, produces dramatic increases in graft force when the knee is flexed to 90°, which could be detrimental to a remodeling graft and lead to subsequent failure of the reconstruction. (10.1177/03635465020300012701)
  • [L4] This novel surgical reconstruction technique aims to reconstruct the PCL closely to its normal anatomy by mimicking the anterolateral and posteromedial bundles, which significantly improves knee stability and kinematics. (10.1016/j.jisako.2023.08.002)
  • [L2] MRI appears to offer only a marginal benefit as the specificity and sensitivity for diagnosing meniscal injuries are poor in patients with a fracture. (10.1302/0301-620x.96b12.34077)
  • [L4] This simple radiographic assessment is reproducible and reliable for clinical use, and useful for the evaluation of ACL reconstructive procedures. (10.1007/s00167-010-1243-9)
  • [L4] Geriatric tibial plateau fractures have unique distribution in classification. (10.1186/s13018-018-0986-8)
  • [L4] MCS repair made with the all-inside method is successful clinically and functionally and in respect of MRI findings. (10.1186/s13018-017-0591-2)
  • [L5] The authors agree that generic statements regarding tunnel placement should no longer be used in modern literature and acknowledge the need for more detailed technical descriptions. (10.1016/j.arthro.2009.05.008)
  • [L3] These results may provide novel reference metrics for the early diagnosis of lateral meniscal injury when MRI is not available. (10.1186/s12891-023-06924-7)
  • [L2] It is recommended that these devices should not be used without objective verification of alignment, either in real-time or with post-operative imaging. (10.1007/s00167-013-2670-1)
  • [L1] The overall estimates with the six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings. (10.2106/jbjs.m.00929)
  • [L4] The outcomes of non-operative treatment of acute isolated PCL avulsion fractures were comparable to those of patients with acute isolated PCL injuries. (10.1007/s00167-020-06175-2)
  • [L1] However, the clinical and radiological outcomes between the two groups were similar. (10.1007/s00167-009-0983-x)
  • [L5] The proposed technique represents a promising adjunct for the management of stable juvenile OCD lesions that fail to heal after 3–6 months of non-operative treatment and for non-displaced, unstable OCD lesions that undergo internal fixation. (10.1007/s00167-013-2375-5)
  • [L4] This treatment protocol can help determine the surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries. (10.1007/s00167-011-1541-x)
  • [L1] No significant differences were found between the 2 arthroscopic repair techniques in terms of functional and radiological results. (10.1177/0363546517695789)
  • [L4] The study presents an alternative method for treating symptomatic ulnar styloid non-unions that provides stable fixation with low risk of implant removal. (10.1177/1753193416638483)
  • [L1] Surgical management is associated with a lower rate of re-dislocation; however, whether surgery produces greater functional outcomes than conservative management is still unclear. (10.1186/s13018-023-03867-6)
  • [L4] This surgical technique may help avoid the complications that can occur with prolonged postoperative use of an external fixator. (10.5435/jaaos-d-16-00573)
  • [L5] The procedure is an anatomical technique that requires minimal access and leads to satisfactory clinical evolution of patients. (10.1136/jisakos-2020-000484)
  • [L4] The reported surgical technique showed excellent to good clinical and radiological results and may be a physeal sparing alternative to previously described procedures. (10.1007/s00167-009-0733-0)
  • [L5] For most repairable tears, the optimal minimal setting may be as short as 8 mm and not likely to be greater than 16 mm. (10.1016/j.arthro.2016.01.026)
  • [L4] The majority of studies do not accurately report key elements of graft history including tissue bank, processing or sterilization technique, or donor age. (10.1177/0363546510382222)
  • [L2] This paper describes the design of a randomized controlled trial to compare MRI-derived signal intensity of ACL grafts one year after transtibial versus anteromedial portal techniques, hypothesizing that the AMP technique will result in better graft maturity. (10.1186/s12891-016-1183-8)
  • [L4] Our findings suggest decreasing surgical time as the surgeon advances through the learning curve, with the initial 75 procedures requiring longer time to perform than subsequent cases. (10.1016/j.arthro.2019.11.121)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L2] Predictors of superior functional outcome after corrective osteotomy are an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20°, and the use of three-dimensional computer-assisted techniques. (10.1177/1753193417711684)
  • [L4] This study found a notable linear decrease in surgical time and the number of cases completed without associated detriment to postoperative outcomes. (10.5435/jaaos-d-24-01307)

See Also

References

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[62] Guided growth in the correction of knee deformity in patients with congenital insensitivity to pain. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02304-w

[63] Shallow knee flexion angle during femoral tunnel creation using modified transtibial technique can reduce femoral graft bending angle in ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5191-0

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4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.