Reduction of increased reclination of the tibial plateau (posterior slope) to improve the anterior stability of the knee joint. Increased posterior reclination of the tibial plateau greater than 12° in combination with recurrent instability after anterior cruciate ligament (ACL) reconstruction. Hyperextension of more than 15° (relative). Anterior skin incision approximately 8-10 cm above the tibial tuberosity. Insertion of two converging guidewires directly below the patellar tendon ending obliquely in the area of the posterior cruciate ligament (PCL) insertion. Control of the wire position with the image intensifier core. Oscillating saw osteotomy. Removal of the wedge and closure of the osteotomy. Osteosynthesis with interfragmentary screw and medial angle-stable plate. Partial load with 10-20 kg for 2 weeks, then step by step increase in load. Mobility: free. To date we have operated on 36patients with recurrent instability after ACL reconstruction (20men, 16women, average age 34.4 years) in the manner described in this article. In 25cases, enlarged bone tunnels were filled with allogeneic bone at the same time. The posterior slope of the tibial plateau could be reduced from an average of 14.5° to8.8°. In 28cases another ACL reconstruction was performed after an interval of 4-12months. The Lysholm score significantly increased from 76.3 points to 89.2 points.

Arotational osteotomy requires acomplete cut of the bone in order to correct maltorsion. An additional correction of the frontal axis can be achieved via an oblique cut of the bone. The osteotomy with bone to bone contact is fixed with an angle stable plate. Symptoms such as anterior knee pain, inwardly pointing knee syndrome, lateral patellar subluxation or dislocation, lateral patellar hypercompression syndrome are a common indication for derivational osteotomy if clinically increased femoral internal rotation and radiologically increased femoral antetorsion is detected. Increased hip external rotation versus internal rotation, increased femoral torsion but no increased internal hip rotation, malcompliance, inability for partial weight bearing, risk of delayed union (nicotine abuse and obesity) as well as patellofemoral arthritis and systematic glucocorticoids, immunosuppressants are (relative) contra-indications. Alateral or optionally medial approach to the distal femur and exposure of the bone with Eva hooks for the osteotomy is done. The use of patient-specific cutting blocks accurately specify the planned extent of derotation and level of incision. Adefined oblique cutting plane of the single-cut osteotomy and derotation will additionally correct/change frontal axis. An additional biplanar osteotomy with an anterior wedge increases intraoperative stability and generates alarger bone contact area for consolidation. With the use of an extra medullary fixation devicepartial weight bearing with 15-20 kg with crutches up to 6weeks is required, but no restriction on knee movement is given. The literature shows significantly improved patient satisfaction regarding patellofemoral stability and knee function.With the use of patient-specific cutting guides, high accuracy of the osteotomy and 3‑dimensional correction can be achieved, while delayed union rate is up to 10%.

Osteochondral lesions of the talus (OLT) with afragment on the talar dome that fail conservative treatment and need surgical treatment can benefit from in situ fixation of the OLT. Advantages of fixation include the preservation of native cartilage, a high quality subchondral bone repair, and the restoration of the joint congruency by immediate fragment stabilization. To improve the chance of successful stabilization, adequate lesion exposure is critical, especially in difficult to reach lesions located on the posteromedial talar dome. In this study we describe the open Lift, Drill, Fill, Fix (LDFF) technique for medial osteochondral lesions of the talus with an osteochondral fragment. As such, the lesion can be seen as an intra-articular non-union that requires debridement, bone-grafting, stabilization, and compression. The LDFF procedure combines these needs with access through amedial distal tibial osteotomy. Symptomatic osteochondral lesion of the talus with afragment (≥ 10 mm diameter and ≥ 3 mm thick as per computed tomography [CT] scan) situated on the medial talar dome which failed 3-6months conservative treatment. Systemic disease, including active bacterial arthritis, hemophilic or other diffuse arthropathies, rheumatoid arthritis of the ankle joint, and malignancies. Neuropathic disease. End-stage ankle osteoarthritis or Kellgren and Lawrence score3 or4 [3]. Ipsilateral medial malleolus fracture less than 6months prior. Relative contra-indication: posttraumatic stiffness with range of motion (ROM) < 5°. Children with open physis: do not perform an osteotomy as stabilization of the osteotomy may lead to early closure of the physis, potentially resulting in symptomatic varus angulation of the distal tibia. In these cases only arthrotomy can be considered. The OLT is approached through amedial distal tibial osteotomy, for which the screws are predrilled and the osteotomy is made with an oscillating saw and finished with achisel in order to avoid thermal damage. Hereafter, the joint is inspected and the osteochondral fragment is identified. The cartilage is partially incised at the borders and the fragment is then lifted as ahood of amotor vehicle (lift). The subchondral bone is debrided and thereafter drilled to allow thorough bone marrow stimulation (drill) and filled with autologous cancellous bone graft from either the iliac crest or the distal tibia (fill). The fragment is then fixated (fix) in anatomical position, preferably with two screws to allow additional rotational stability. Finally, the osteotomy is reduced and fixated with two screws. Casting includes 5weeks of short leg cast non-weightbearing and 5weeks of short leg cast with weightbearing as tolerated. At 10-week follow-up, aCT scan is made to confirm fragment and osteotomy healing, and patients start personalized rehabilitation under the guidance of aphysical therapist.

Early onset scoliosis is defined as aspinal deformity originating in the first 10years of life. Growth-preserving spinal instrumentation has therefore been designed to preserve growth of spine and chest wall and lungs to avoid serious pulmonary complications after early spine fusion. Indications, surgical technique and results of the vertical expandable prosthetic titanium rib (VEPTR) technique, traditional growing rods (TGR), and magnetically controlled growing rods (MCGR) will be described. Indications for VEPTR are so-called mixed congenital deformities (type3) associated with vertebral malformations in association with chest wall deformities, especially fused ribs. There are also indications for neuromuscular or syndromic early onset scoliosis with bilateral rib-to-ilium constructs. However, most of those deformities are currently treated with either GR or MCGR in most centers. GR and MCGR are currently the treatment of choice for the majority of early onset scoliosis. There is no indication for growth-preserving strategies if the patients are mature or there is only little growth remaining. In these cases, final fusion should be performed. While the VEPTR technique involves an extensive approach with muscular dissections to the thoracic cage including rib osteotomies and thoracotomies, treatment with TGR or MCGR is minimally invasive, only exposing proximal and distal anchor points, leaving most of the spine including the apex undisturbed. Early mobilization is usually possible after 24-48 h. Braces may have to be prescribed for patients with osteopenia, noncompliance, or arisk to fall. Since 2005, more than 200patients were treated with the VEPTR technique, more than 200 patients with the MCGR technique, and about 30patients with the TGR technique in our department. Complication rates are high with all techniques including the law of diminishing returns, autofusion, bone anchor-related complications like loosening or migration of implants, failure to distract and proximal junctional kyphosis. In our own series of 13patients below age 3years, VEPTR proved to be effective for mixed deformities. In other studies, we were able to show that physiological growth with MCGR can be maintained for 2-3years but spinal growth declines after that period with acceptable complications. Complication rates in most studies are lower with MCGR compared to TGR and VEPTR. Therefore, it is currently the treatment of choice for most early onset scoliosis patients.

At the end of surgical therapy, the access is closed with sutures. Surgical sutures are thus used to adapt wound edges and tissues. The task of the suture material is to hold the tissues together until healing. For patients, acosmetically good suture is often the sign of good surgery. Different tissues and layers have different requirements regarding the suture material. The different types from monofil to polyfil, braided, from absorbable to nonabsorbable are presented. The classification of suture strengths is compared. The areas of application of different strengths and the duration until removal of the sutures for the different body regions are presented. The one-hand and two-hand techniques of surgical knots are explained in detail. The technique of suture removal is presented. In the online material, the suture materials of different composition and manufacturers can be compared.

Presentation of aminimally invasive surgical approach for the treatment of scapular fractures and the clinical outcome using this technique. Displaced extra-articular fractures of the scapula body and glenoid neck (AO 14B and 14F) and simple intra-articular fractures of the glenoid. Complex intra-articular fractures and isolated fractures of the coracoid base. Make astraight or slightly curved incision along the lateral margin of the scapula leaving the deltoid fascia intact. Identify the interval between the teres minor muscle and infraspinatus to visualize the lateral column, whilst retracting the deltoid to visualize the glenoid neck. Reduce and align the fracture using direct and indirect reduction tools. Asecond window on the medial border of the scapula can be made to aid reduction and/or to augment stability. Small (2.0-2.7 mm) plates in a90° configuration on the lateral border and, if required, on the medial border are used. Intra-operative imaging confirms adequate reduction and extra-articular screw placement. Direct postoperative free functional nonweight-bearing rehabilitation limited to 90° abduction for the first 6weeks. Sling for comfort. Free range of motion and permissive weight-bearing after 6weeks. We collected data from 35patients treated with minimally invasive plate osteosynthesis (MIPO) between 2011 and 2021. Average age was 53 ± 15.1years (range 21-71years); 17had atypeB and 18atypeF fracture according the AO classification. All patients suffered concomitant injuries of which thoracic (n = 33) and upper extremity (n = 25) injuries were most common. Double plating of the lateral border (n = 30) was most commonly performed as described in the surgical technique section. One patient underwent an additional osteosynthesis 3months after initial surgery due to pain and lack of radiological signs of healing of afracture extension into the spine of the scapula. In the same patient, the plate on the spine of scapula was later removed due to plate irritation. In 2patients postoperative images showed ascrew protruding into the glenohumeral joint requiring revision surgery. After standardisation of intra-operative imaging following these two cases, intra-articular screw placement did not occur anymore. No patient suffered from iatrogenic nerve injury and none developed awound infection.

The goal of osteotomy is either to restore pretraumatic anatomic conditions or to shift the load to less affected compartments. Indications for computer-assisted 3D analysis and the use of patient-specific osteotomy and reduction guides include "simple" deformities and, in particular, multidimensional complex (especially posttraumatic) deformities. General contraindications for performing acomputed tomography (CT) scan or for an open approach for performing the surgery. Based on CT examinations of the affected and, if necessary, the contralateral healthy extremity as ahealthy template (including hip, knee, and ankle joints), 3D computer models are generated, which are used for 3D analysis of the deformity as well as for calculation of the correction parameters. For the exact and simplified intraoperative implementation of the preoperative plan, individualized guides for the osteotomy and the reduction are produced by 3D printing. Partial weight-bearing from the first postoperative day. Increasing load after the first x‑ray control 6weeks postoperatively. No limitation of the range of motion. There are several studies that have analyzed the accuracy of the implementation of the planned correction for corrective osteotomies around the knee joint with the use of patient-specific instruments with promising results.

Surgical treatment of intra-articular calcaneus fractures via aminimally invasive approach. Intra-articular dislocated calcaneus fractures. Fracture older than 14days; poor soft tissue quality in the surgical area. Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsalIV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of aSchanz screw in the calcaneal tuberosity from lateral or posterior as areduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing acannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X‑rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath. Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8weeks; subsequently increased load bearing. Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

Three-dimensional correction of the bony alignment in the frontal and sagittal plane of the proximal tibia; surgery is performed via an open- or closing-wedge osteotomy to improve ligament stability and reduce joint degeneration. Chronic anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) instability and ligament revision surgeries; subjective knee instability in patients who are ambitious athletes and people who do physical labor; moderate joint degeneration with meniscus and cartilage damage, post-traumatic deformities. Time pressure (immediate meniscus surgery, since planning and production of patient-specific tools is time-consuming), lack of compliance (need for partial weight bearing, crutches), excessive smoking, vascular pathologies. Planning based on computed tomography (CT) data, determination of the axis of rotation with open or closing wedge, or dome osteotomy; production of corresponding patient-specific cutting blocks. Surgery is performed using the known standard approaches for a high tibial osteotomy (HTO). Exact positioning of cutting guides on the exposed bone. Sawing and adjusting the correction using an osteotomy chisel so that the reduction guide can be attached. Fixation of the achieved correction with angle-stable plate fixator. Partial weight bearing based on the extent of the correction for 6weeks, free range of motion if no additional ligamentous reconstruction was performed. Subsequent full weight bearing after X‑ray and, if necessary, CT control. No general results can be presented, since the surgical procedure, the indication, and the patient group are extremely heterogeneous. Accuracy of the cutting blocks used has been presented in other studies and is given as 0.8° ± 1.5° in relation to the frontal axis. However, the intraoperative change in the correction and adaptation to the surgical site that is presented depends on the surgeon and can greatly influence the extent of correction in terms of accuracy in complex corrections.

Restoration of the original anatomy with reduction of both current symptoms and risk of posttraumatic osteoarthritis. Symptomatic intra- or extra-articular malunion due to limitation of movement and/or painful function, intra-articular step of > 1 mm, instability of the distal radioulnar joint. Minimal deformity. Pre-existing osteoarthritis Knirk and JupiterII or higher. Simpler surgical alternative, e.g., ulna shortening osteotomy. Smoking or advanced age are not contraindications. Preoperative assessment and performance of abilateral computed tomography (CT). Three-dimensional (3D) malposition analysis and calculation of the correction. Planning of the corrective osteotomy on the 3D model and creation of patient-specific drilling and sawing guides. Performing the 3D-guided osteotomy. Early functional unloaded mobilization with the splint for 8weeks until consolidation control with CT. Significant reduction of the step to < 1 mm (p ≤ 0.05) can be achieved with intra-articular corrections. In extra-articular corrective osteotomies, amean residual rotational malalignment error of2.0° (± 2.2°) and atranslational malalignment error of 0.6 mm (± 0.2 mm) is achieved. Single-cut osteotomies in the shaft region can be performed to within afew degrees for rotation (e.g., pronation/supination4.9°) and for translation (e.g., proximal/distal, 0.8 mm). After surgery, amean residual 3D angle of5.8° (SD3.6°) was measured. Furthermore, surgical time for 3D-assisted surgery is significantly reduced compared to the conventional technique (140 ± 37 vs 108 ± 26 min; p < 0.05). Thus, the progression of osteoarthritis can be reduced in the medium term and improved mobility and grip strength are achieved. The clinical outcome parameters based on patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) scores are roughly comparable.