Danko Dan Milinkovic

Background: Shifting surgeries from the stationary to the outpatient setting is seen as a suitable way to increase efficiency in the health care system. A substantial increase in outpatient procedures can therefore be observed internationally—particularly in the field of orthopedics. However, the interests and needs of patients are often insufficiently taken into account in this process. The “Power-AOP” research project was initiated to identify the associated challenges in the area of patient empowerment and to develop solutions. Objective: Using the field of orthopedics as an example, the Power-AOP project investigates how patient empowerment can be strengthened in the context of outpatient surgery. Methods: Using a mixed methods approach, health policy recommendations will be developed that aim to strengthen patient empowerment in the context of outpatient surgery. The project is scheduled to run for 3 years and comprises 6 work packages, with a total of 10 modules. In the first step, a scoping review was carried out to map the existing literature. This is followed by focus groups and interviews with patients and health care providers to gain deeper insights into their experiences and perspectives. The results will be quantified using a questionnaire-based survey. In order to identify a suitable patient population for this survey, an analysis of claims data will be conducted beforehand. The results will then be discussed and refined in 2 stakeholder workshops with key players in the health care system. In the final phase, a concept will be developed that contains actionable recommendations for strengthening patient empowerment in the context of outpatient care. Results: The project began in April 2025. The claims data analysis and the scoping review have been completed, and a manuscript for the review is currently being prepared. The focus groups and interviews were conducted with 19 health care providers and 26 patients. Data analysis is in progress. The quantitative survey is planned for May 2026 to March 2027. The workshops are scheduled for the second and fourth quarters of 2027. The project will conclude with the final results in March 2028. Conclusions: This project will help to improve patient empowerment in the context of outpatient surgery. This allows patients to take a more active role in the process. On the one hand, this can lead to greater satisfaction with the process, particularly among patients. On the other hand, more active participation by patients can improve outcomes and prevent unnecessary readmissions or additional treatments.

Purpose: To evaluate current preferences, techniques and indications regarding the use of the quadriceps tendon (QT) autograft for anterior cruciate ligament reconstruction (ACLR) among members of the International Quadriceps Tendon Interest (IQTI) group. Methods: An online survey consisting of 30 single‐ and multiple‐choice questions was distributed to all IQTI members ( n = 45), representing an international group of orthopaedic surgeons with specific expertise in QT‐based ACLR. The survey was conducted in conjunction with the second IQTI meeting, and responses were collected over a 2‐month period (June–July 2025). Results: Thirty‐two high‐volume, experienced surgeons completed the questionnaire (32/45; response rate, 71%; 28 male and 4 female). The QT was the preferred primary graft choice for ACLR in 61% ( n = 20) of respondents, while 89% ( n = 28) used it for revision ACLR and 72% ( n = 23) for multiligamentous injuries. Preoperative QT measurement with magnetic resonance imaging (MRI) or ultrasound was performed always or often by 34% ( n = 11). Tendon defect closure after harvest was routinely performed by 94% ( n = 30), and 33% ( n = 11) reported always or often harvesting a bone block. Adjustable‐loop suspensory fixation was most commonly used on the femoral side (61%, n = 20), whereas tibial fixation was most frequently achieved with interference screws (72%, n = 23). One‐third of surgeons (33%, n = 11) reported modifying their rehabilitation protocol when using QT compared with other grafts. The most frequently observed short‐term complications were transient quadriceps weakness and extensor lag. Conclusion: This international survey shows that the QT autograft is a well‐established option in ACLR among experienced knee surgeons, particularly in revision and complex settings. At the same time, persistent variability in primary graft selection and reported rehabilitation and technical considerations indicate that QT use remains individualized within a spectrum of effective autograft choices. Level of Evidence: Level V, expert statement.

Purpose: The main goal was to perform a modified Delphi process with the Ligament Injuries Committee of the German Knee Society (DKG) to structure and optimize the management of isolated posterior cruciate ligament (PCL) injuries. Methods: A structured modified Delphi approach was used to develop an expert statement. Steering group formulated an initial questionnaire and distributed it to 15 experienced knee surgeons (male/female 13/2, mean age 45 ± 5 years) of the working group in Round 1. Thirty‐one statements covering five thematic topics were then derived from the responses and comprehensive literature search (Medline, Scopus and Cochrane) using variations of different search terms (literature group). The statements underwent two rating cycles by the working group, using a 5‐point Likert scale in Round 2 and as a binary ‘agree/disagree’ in the final third round. Levels of evidence were assigned to each statement using standardized A–E and GRADE grading systems based on the available data. Results: High agreement (≥80%) was achieved for 24 of the 31 statements (range, 83%–100%), whereas for 7 agreement was <80% (range 63%–74%). The highest levels of agreement were reached for imaging modalities, treatment of PCL tibial avulsions, and preservation of native PCL fibres in reconstruction techniques, whereas the greatest divergence was observed regarding the role of leg axis and slope analyses and indications for corrective osteotomies, use of augmentation in reconstruction and post‐operative rehabilitation protocols. The available level of evidence across studies in the literature was predominantly low to moderate. Of the 31 statements, 17 were graded as expert opinion (E, GRADE: very low), 12 as case series (C; GRADE: low), and only 2 achieved higher levels of evidence (B2, GRADE: moderate). Conclusion: By providing structured treatment protocols, this Delphi‐based structured expert statement can support clinicians in day‐to‐day decision‐making and ultimately improve patient care and outcomes. Study Design: Expert survey. Level of Evidence: Level V.

Purpose: This study aimed to evaluate the radiological and patient‐reported outcome measures (PROMs) following spheroid‐based matrix‐induced autologous chondrocyte implantation combined with autologous bone grafting (MABCI) for the treatment of osteochondral defects of the knee. Methods: In this retrospective cohort analysis of prospectively collected data, 28 consecutive patients with 29 defects of the femoral condyle (male: 15, female: 13, mean age 27.3 ± 9.8 years, mean defect size 3.7 ± 1.6 cm²) treated with MABCI were included. Radiological assessments were performed using 3T magnetic resonance imaging (MRI) to evaluate cartilage thickness, T2 relaxation times and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 scores. Clinical outcomes were assessed using validated PROMs, including the International Knee Documentation Committee (IKDC) score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Lysholm scale and the Patient‐Reported Outcomes Measurement Information System 29‐Item Profile (PROMIS‐29). Correlation analyses were conducted to evaluate associations between radiological parameters and PROMs. Results: The analysis was conducted at a mean follow‐up of 44.4 ± 21.6 months. Cartilage thickness in the repair tissue exceeded that of the reference cartilage (3.4 ± 0.9 mm vs. 3.0 ± 0.5 mm; p = 0.036), while T2 relaxation times in the repair tissue were within physiological range (50.5 ± 40.0 ms vs. 41.3 ± 5.4 ms; n.s.). The mean MOCART 2.0 score was 61.3 ± 13.0 (volume fill: 16.1 ± 3.7, integration with adjacent cartilage: 12.9 ± 3.3), reflecting satisfactory repair quality. All clinical scores showed significant improvement compared to the preoperative condition (IKDC: 70.6 ± 13.2 vs. 54.8 ± 17.5, p < 0.001; KOOS: pain 78.7 ± 16.9 vs. 66.1 ± 18.6, p = 0.002, symptoms 75.6 ± 16.0 vs. 65.8 ± 19.1, p = 0.006, ADL 86.8 ± 14.0 vs. 77.6 ± 16.8, p = 0.003, sport 63.0 ± 24.2 vs. 47.3 ± 26.9, p = 0.009, quality of life (QoL) 51.0 ± 22.7 vs. 39.6 ± 17.5, p = 0.014; numeric pain rating scale: 3.0 ± 2.2 vs. 5.2 ± 2.4, p < 0.001). A greater cartilage thickness was associated with reduced pain intensity ( r = −0.457, p = 0.013) and improved QoL ( r = 0.429, p = 0.020), indicating that better structural repair is associated with improved patient satisfaction. Conclusions: MABCI results in satisfactory cartilage regeneration and subchondral remodelling in addition to significant improvements in patient satisfaction and overall QoL. Level of Evidence: Level III.

Purpose: Autologous chondrocyte implantation (ACI) is a complex procedure for cartilage defects, requiring patient understanding of treatment and recovery, as health literacy impacts outcomes. This study evaluated the quality and readability of AI‐generated ACI materials using ChatGPT‐4o as adjuncts to physician‐led education. We compared responses from the native model and a fine‐tuned version and hypothesised that the fine‐tuned model would provide improved quality and readability. Methods: Twenty‐two frequently asked questions were identified using Google's ‘People Also Asked’ feature. Two ChatGPT‐4o configurations were evaluated: the native model and a fine‐tuned version (ACI guide) optimised by instruction‐based fine‐tuning and reinforcement learning from human feedback. Two orthopaedic surgeons independently scored the responses. Quality was assessed using the DISCERN criteria and readability by the Flesch Reading Ease Score (FRES) and Flesch‐Kincaid Grade Level (FKGL). Interrater reliability was determined using intraclass correlation coefficient (ICC) in a two‐way mixed‐effects model. Results: The fine‐tuned ACI Guide outperformed the native ChatGPT‐4o on all parameters. The native model produced poor‐quality responses with a mean DISCERN score of 35.29 ± 5.0 (range: 23–45), while the ACI Guide achieved a significantly higher score of 43.18 ± 3.92 (range: 34–53; p < 0.001), reflecting moderate quality. Regarding readability, the native model reached FKGL of 13.45 ± 1.30 (university sophomore level) . In contrast, the ACI Guide achieved FKGL of 9.25 ± 1.64 (9th‐grade level). The FRES was also significantly higher for the ACI Guide (49.59 ± 10.44) than the native model (35.68 ± 5.08; p < 0.001). Interrater reliability was strong (ICC = 0.767), indicating good agreement. Conclusions: ChatGPT‐4o's responses were of poor quality and written at a readability level substantially exceeding recommended thresholds for patient education materials, limiting their applicability in clinical communication and patient education. Fine‐tuning ChatGPT‐4o improved the readability and quality of ACI patient education materials, generating content closer to the 8th–9th‐grade level. It may serve as a useful adjunct to physician‐led education in enhancing patient understanding of complex orthopaedic procedures. Level of Evidence: Level V.

Purpose: This study aimed to evaluate whether age at the time of surgery influences patient‐reported outcome measures (PROMs) in patients undergoing tailored surgical treatment for lateral patellar dislocation (LPD), including deepening trochleoplasty (TP). Methods: This retrospective cohort study used a prospectively maintained database. The Banff Patella Instability Instrument 2.0 (BPII 2.0) and a numerical analogue scale (0–10) for patellofemoral pain (PFP) and subjective knee joint function were used to assess patients’ disease‐specific quality of life before and after surgery. Preoperative cartilage status was evaluated via the semiquantitative Area Measurement and Depth & Underlying Structures (AMADEUS) scoring system. Results: Twenty‐nine patients (m/f 4/25) were ≥30 years of age (mean: 35.3; range: 30–51) and formed the study group (SG), and 127 patients (m/f 39/88) were p = 0.27). The BPII 2.0 increased from 48.7 ± 21.4 to 85.4 ± 10.7 points ( p < 0.0001) (SG) and from 44 ± 20.6 to 78.6 ± 18.4 points ( p < 0.0001) (CG), without any significant difference between the groups at the final follow‐up ( p = 0.24). PFP and subjective knee joint function also improved significantly in both groups ( p < 0.0001; p < 0.0001), without any significant difference between the groups at the final follow‐up ( p = 0.08; p = 0.3). In the SG and the CG, 88.2% and 89.7% of patients, respectively, achieved an MCID of 10 points calculated for the BPII 2.0 ( p = 0.99), and no correlation was found for ‘age’ or any evaluated post‐operative PROM (all p > 0.1). The AMADEUS scores were 80.1 ± 15 points (CG) and 82.1 ± 14.2 points (SG) ( p = 0.57), respectively. Conclusion: Deepening TP, as part of a tailored surgical treatment plan for recurrent LPD, yielded satisfying results, irrespective of patient age at the time of surgery. Level of Evidence: Level III.

Purpose: This study aimed to evaluate the clinical and functional outcomes of autologous bone grafting with spheroid‐based matrix‐induced autologous chondrocyte implantation (MABCI) for osteochondral defects of the knee by analysing pre‐ and postoperative patient‐reported outcome measures (PROMs). Postoperative gait analysis was conducted and compared with a matched healthy control group to investigate biomechanical deviations.Methods: A total of 35 patients (m: 21, f: 14; mean defect size: 4.2 ± 2.4 cm², localisation: femoral condyle: 31, patellofemoral: 5) were analysed. The mean follow‐up was 42.6 ± 22.8 months. International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), PROMIS 29 profile, and a questionnaire on patient perception of treatment success were assessed to evaluate PROMs. 3D‐instrumented gait analysis (GRAIL, Motek) was used to assess lower extremity kinematics, kinetics and vertical ground reaction forces, compared to sex‐, age‐ and body mass index‐matched healthy controls.Results: All clinical scores showed significant improvement compared to the preoperative condition (IKDC: 73.1 ± 10.1 vs. 56.6 ± 17.2, p < 0.01; KOOS subcategories: pain 82.0 [±12.7] vs. 70.7 [±16.7] [p < 0.01], symptoms 79.1 [±20.3] vs. 68.9 [±13.9] [p < 0.01], activities of daily living 90.1 [±11.2] vs. 80.5 [±15.6] [p < 0.01], sport and recreational function: 65.3 [±19.3] vs. 51.3 [±26.29] [p < 0.01], quality of life 52.2 [±18.6] vs. 42.6 [±18.6] [p < 0.01]; numeric pain rating scale: 2.7 ± 2.0 vs. 5.0 ± 2.5, p < 0.01). The analysed patients reported a high satisfaction rate (94.3%). Self‐selected walking speed was significantly lower than in healthy controls (1.17 ± 0.17 m/s vs. 0.98 ± 0.18 m/s, p < 0.01). Peak knee flexion angle (PKA) during loading response was significantly smaller (9.6° ± 7.0 vs. 17.7° ± 4.6, p < 0.01), and knee extension moment was significantly reduced (0.1 Nm/kg ± 0.2 vs. 0.4 Nm/kg ± 0.2, p < 0.01).Conclusion: MABCI is an effective treatment for osteochondral knee defects, showing significant improvements in all evaluated PROMs. Postoperative gait analysis revealed abnormal gait patterns, including reduced PKA and lower knee extension moment, suggesting a need for further rehabilitation to optimise functional recovery.Level of Evidence: Level III.