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Purpose: The aim of this study was to determine the clinical and functional outcome of a salvage surgical approach with the combined procedures meniscal allograft transplantation (MAT), anterior cruciate ligament reconstruction (ACLR), and high tibial osteotomy (HTO), in a cohort of patients treated for complex knee lesions evaluated up to a mid-term follow-up. Methods: Eight patients (38.8 ± 4.6 years, 88% males) were treated arthroscopically with MAT without bone plugs combined with primary or revision ACLR and HTO and evaluated at basal, at a minimum of two years (short follow-up), and at a mean follow-up of 5.1 years (mid-term follow-up) with the VAS score for pain, Lysholm score, IKDC subjective score, WOMAC Osteoarthritis index, and Tegner score. Physical examination (Lachman and pivot-shift tests, arthrometer assessment) and radiographic evaluation (pre- and post-operative x-rays) were obtained. Complications and failures were also recorded. Results: A statistically significant improvement was observed from baseline to five years in all clinical scores. In particular, the IKDC subjective score improved from 33.3 ± 20.7 to 73.1 ± 18.4 at short follow-up (p < 0.05), up to 78.3 ± 9.8 at the final follow-up (p < 0.05). A similar trend was demonstrated with the Lysholm, VAS, WOMAC, and Tegner score, even though only one patient reached the pre-injury activity level. Two patients had a worsening of the Kellgren-Lawrence (KL) grade from preoperative (grade 1) to final follow-up (grade 2). No major complications and surgical failures were documented. Conclusion: The combined procedure of MAT, ACLR, and HTO presents few complications and failures and showed to be a valid option to reduce pain, recover knee function, and slow down the osteoarthritis process even in complex patients, with good and stable results up to a mid-term follow-up. [ABSTRACT FROM AUTHOR]

Background: Knee stiffness after total knee arthroplasty (TKA) often leads to pain and discomfort, failing to meet patients' expectations on the surgical procedure. Despite the growing debate on the topic, a comprehensive literature analysis of stiffness causes has never been conducted. Thus, the purpose of the present study was to systematically review the literature regarding the main causes of stiffness after TKA. Methods: Pubmed Central, Scopus, and EMBASE databases were systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines for studies on stiffness and pain or discomfort after TKA through November 2020. Overall, 25 articles matched the selection criteria and were included in the study. Clinical relevance and strength of evidence of the included studies were graded using the risk of bias and the methodological index for non-randomized studies quality assessment tools. Results: The main causes of pain and discomfort due to stiffness were surgery-related issues, i.e., component malpositioning and over-voluming, implant loosening, psychological distress, and obesity, which could be considered "modifiable" factors, and expression of profibrotic markers, high material hypersensitivity-related cytokines level, male gender, previous contralateral TKA, and high pre-operative pain, which could be considered "non-modifiable" factors. Conclusion: The use of alternative technologies such as surgical robots, anatomy-based devices, and more inert and less stiff component materials could help in reducing stiffness caused by both modifiable and even some non-modifiable factors. Furthermore, early diagnostic detection of stiffness onset could consistently support surgeons in patient-specific decision-making. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this systematic review was to summarise and evaluate the clinical outcomes of the collagen meniscus implant (CMI) and its complication and failure rates. These data were then used to evaluate the results of the CMI at different follow-up time periods and investigate possible differences in the behaviour of lateral and medial CMI. Methods: A comprehensive search was performed in PubMed, MEDLINE, CINAHL, Cochrane, EMBASE and Google Scholar databases using various combinations of the following keywords: 'collagen meniscus implant' or 'collagen meniscal implant'. All studies evaluating medial or lateral CMI using the Lysholm score, visual analogue scale (VAS) for pain, Tegner activity scale and subjective or objective International Knee Documentation Committee (IKDC) scores were included in the systematic review. Results: Eleven studies were included in the systematic review. The pooled number of patients involved in CMI surgery were 396 (90.2 % medial, 9.8 % lateral), with a mean age at surgery of 37.8 years. Concomitant procedures were present in 48.8 % of patients; most of them were anterior cruciate ligament (ACL) reconstruction, high tibial osteotomy (HTO) and microfractures. The Lysholm score and VAS for pain showed an improvement at six months up to ten years. No noticeable differences were present comparing short-term values of Lysholm score between medial and lateral CMI. The Tegner activity level reached its peak at 12 months after surgery and showed a progressive decrease through five and ten years post CMI implantation, however always remaining above the pre-operative level. Only a few knees were rated as 'nearly abnormal' or 'abnormal' at IKDC grading at all follow-up evaluations. Conclusions: The CMI could produce good and stable clinical results, particularly regarding knee function and pain, with low rates of complications and reoperations. [ABSTRACT FROM AUTHOR]

Purpose: The purpose is to verify the intra- and inter-operator reliability of an extramedullary (EM) accelerometer-based smart cutting guide for distal femoral resection during primary total knee arthroplasty (TKA). The hypothesis of the present study was that the use of the device would result in a good correlation between different operators with a difference between repeated measurements of less than 1°. Methods: Twenty-five not consecutive patients with knee osteoarthritis undergone to primary TKA using an EM inertial-based cutting guide to perform distal femoral resection. In order to assess the agreement in femoral axis definition of the device, two operators performed three time each the manoeuvres necessary to define axis. Inter-rater agreement was evaluated with Bland and Altman agreement test. Intra-rater repeatability was evaluated analysing average results distribution of repeated measurements. Accuracy of the device was evaluated comparing differences between intra-operative device data with final implant alignment measured on post-operative longstanding x-rays using Students' t test. Results: Agreement between the two operators was statistically significant (p < 0.05) with a bias of − 0.4° (95% CI − 0.6° to − 0.2°). Average difference between cut orientation measured with device and final implant position, measured on x-rays, was 0.2° (95% CI − 1.5° to 1.7°) with no statistical difference between the two measurements. Final implant alignment, measured on x-ray, was 90.2°, with 95% of cases distributed within range 88.0° to 92.0° for varus-valgus and 2.8° and with 95% of cases distributed within range 2.0° to 4.0° for flexion–extension. Conclusions: The EM accelerometer-based smart cutting guide used to perform distal femoral resection during primary TKA demonstrated a good intra- and inter-operator reliability in the present in vivo study. [ABSTRACT FROM AUTHOR]

Purpose: Meniscal repairs are the most common associated procedures during ACL reconstruction, but they present challenging indications and possible risks of complications or failures. The aim of the present study is to assess the clinical outcomes of all-inside meniscal repairs in the setting of ACL reconstruction.Methods: Twenty patients with ACL reconstruction and all-inside meniscal repair were compared to 20 patients with isolated ACL reconstruction. All patients were prospectively evaluated pre-operatively, at four month, and 18-month follow-up with KT-1000, Kira accelerometer for pivot-shift, KOOS, Marx score, and SF-36. Meniscal healing and presence of peri-meniscal cysts were assessed on standardized 1.5-T MRIs performed at 18 months.Results: Twenty-one meniscal repairs were performed in 20 patients (81% medial, 19% lateral). At 18 months, 48% had complete healing, 38% had incomplete healing, and 14% had no healing. Peri-meniscal cysts were present in 33% of cases. Worst pre-operative KOOS pain (p = 0.0435) and ADL (p = 0 .0201) were present in patients with meniscal lesion, while no differences were present at four months and 18 months between patients with or without meniscal repair (p > 0.05). No significant differences were noted stratifying patients according to meniscal healing or cyst presence, except of a lower Qol KOOS subscale in patients with peri-meniscal cysts (p = 0.0430).Conclusions: Meniscal repairs produced good short-term results when performed in combination to ACL reconstruction. Full or partial healing at MRI was present in 86% of cases. One patient out of three developed peri-meniscal cysts. [ABSTRACT FROM AUTHOR]

Purpose: To compare the results of two groups of patients affected by osteochondritis dissecans (OCD) of the knee and treated with either osteochondral autologous transplantation (OAT) or bone-cartilage paste grafting (PG). Methods: A total of 27 patients affected by OCD lesions of the femoral condyles were included: 15 treated with OAT, 12 with PG, with comparable baseline characteristics (mean age 22.4 ± 7.2 vs. 24.2 ± 8.5 p = n.s., mean defect size 2.2 ± 1 cm2 vs 2.6 ± 1 cm2p = n.s.). Patients were evaluated pre-operatively and at 24 and 84 months post-operatively with the International Knee Documentation Committee (IKDC) subjective and objective scores. Sport activity level was evaluated with the Tegner activity score. Adverse events and failures were also recorded. Results: The IKDC subjective score improved significantly in both groups. At 24 months, a significant improvement from 53.4 ± 9.1 to 80.8 ± 12.9 (p = 0.005) was obtained in the OAT group and from 44.6 ± 11.0 to 71.4 ± 25.3 in the PG group (p = 0.008). A further statistically significant increase was observed at 84 months in both groups. No significant differences were found between OAT and PG at both follow-ups. One OAT patient required post-operative knee mobilization under narcosis and two complained of donor site symptoms. More failures were documented in the PG vs OAT group (25% vs 0%; p = 0.043). Conclusion: Both PG and OAT provided overall satisfactory results up to 84 months follow-up. However, while PG presents the advantages of a less invasive approach with lower adverse events, the higher failure rate of PG should be considered when choosing between these two surgical treatment options for restoration of the articular surface in patients affected by knee OCD. [ABSTRACT FROM AUTHOR]

Purpose: Degenerative ankle arthropathy is a debilitating and increasingly widespread condition with worsening of quality of life. In last years, total ankle replacement has increased indications, thanks to advances in surgical technique, materials and design that provided new solutions for surgeons. The purpose of this study is to evaluate the effectiveness of total ankle replacement (TAR), implanted using a trans-fibular lateral approach in patients with high-grade degenerative arthropathy, in terms of clinical, functional and radiological outcomes and possible complications. Methods: This retrospective study included 73 patients, aged between 47 and 79 years (mean age 61.7 ± 14.2 years), who underwent trans-fibular total ankle arthroplasty. All patients were followed up for at least two years post-operatively with mean follow-up 31.2 ± 8.1 months and have been evaluated clinically and radiographically both pre-operatively and post-operatively. Results: Patients demonstrated a significant improvement in average AOFAS score, SF-36 score and VAS scale. Average plantarflexion improved from 9.9° ± 4.2 to 18.4° ± 6.3 and dorsiflexion from pre-operative mean value of 6.8° ± 5.8 to 17.2° ± 3.1 post-operative. Complications recorded in our series were 16 (21.9%), specifically 2 major complications and 14 minor complications. Conclusions: This study found that trans-fibular total ankle replacement is a safe and effective option for patients with ankle osteoarthritis, resulting in improvement of patient-reported outcomes, range of motion, and radiographic parameters. However, further studies are required to determine long-term performance of these implants. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the available literature on the use of bone marrow aspirate concentrate (BMAC) and summarize the current evidence supporting its potential for the injective treatment of joints affected by osteoarthritis (OA). Methods: A systematic literature search was conducted on three electronic databases (PubMed, Embase, and Cochrane Library) in April 2020, using the following string: "((bone marrow concentrate) OR (BMC) OR (bone marrow aspirate concentrate) OR (BMAC)) AND (osteoarthritis)", and inclusion criteria: clinical and preclinical (animal) studies of any level of evidence, written in English language, and evaluating the intra-articular or subchondral use of BMAC for the injective treatment of OA joints. Results: The publication trend remarkably increased over time. A total of 22 studies were included in the qualitative data synthesis: four preclinical studies and 18 clinical studies, for a total number of 4626 patients. Safety was documented by all studies, with a low number of adverse events. An overall improvement in pain and function was documented in most of the studies, but the clinical studies present significant heterogeneity, few patients, short-term follow-up, and overall poor methodology. Conclusion: There is a growing interest in the field of BMAC injections for the treatment of OA, with promising results in preclinical and clinical studies in terms of safety and effectiveness. Nevertheless, the current knowledge is still preliminary. Preclinical research is still needed to optimize BMAC use, as well as high-level large controlled trials to better understand the real potential of BMAC injections for the treatment of patients affected by OA. [ABSTRACT FROM AUTHOR]

Purpose: An unsatisfactory reduction and internal fixation of an ankle fracture can result in an alteration of the anatomical axes and distribution of the load on the ankle, with consequent development of chronic pain and articular degeneration. The aim of this study is to evaluate the results of the articular re-balancing with realignment and lengthening of the fibula in case of malunited distal fibular fractures. Methods: A review of prospectively collected data was performed for all patients with a diagnosis of malunion of the fibula and underwent ankle joint re-balancing with fibular lengthening. Twenty-three patients, with a mean age of 39.4 ± 13.1 years, have been evaluated using radiographic parameters, American Orthopaedic Foot and Ankle Surgeons ankle-hindfoot, Ankle Activity scale, and SF-36 score at six, 12, 24, and 36 months post-operatively. Results: All cases treated showed at follow-up the osteotomy healed in good correction of the deformities. Clinical scores showed a clear improvement: final 36-month mean AOFAS was 74.0 ± 8.9 point, final 36-month mean HALASI score was 4.9 ± 0.9 points, 36-month follow-up SF-36 score showed an average score of 73.2 ± 10.7 points. Pre- and post-operative radiographic parameters have been registered and described. Conclusions: The ankle joint is a complex structure, and even minor changes of the structure of this joint can significantly compromise its functionality. Ankle joint re-balancing is an effective surgical procedure in case of fibular malunion. This procedure, in patients carefully selected, could procrastinate more disabling surgical procedure, as arthrodesis or prosthesis. [ABSTRACT FROM AUTHOR]

Purpose: Italy is one of the more severely affected countries in the world by the recent COVID-19 outbreak. The aim of this report is to describe how COVID-19 affected the life and organization of one of the main orthopaedic hospitals of the country, and which measures were implemented to face the outbreak. Methods: A personal interview has been conducted with four doctors involved in the management of COVID-19 outbreak in one of the main orthopaedic hospitals of Italy. Results: Hospital was re-organized, elective surgeries were cancelled, and only trauma surgeries were allowed, together with oncologic and urgent cases. Since the number of cases among patients and healthcare workers increased, the hospital management responded not only with a massive testing campaign aimed at detecting contact histories but also with an additional testing campaign for asymptomatic healthcare workers. Conclusion: The main lection is that any actions should be quick and decisive, for 1 week during the COVID-19 epidemic could make the difference. [ABSTRACT FROM AUTHOR]

Purpose: Although long-term reports of total hip arthroplasty (THA) showed successful results, instability remains a major complication. Recently, dual-mobility cups (DMC) have gained more and more interest among clinicians, with encouraging results in terms of lower rate of dislocation associated with good clinical results, but a lack of evidence exists regarding the real efficacy of this implant design compared to traditional fixed-bearing total hip arthroplasties.Methods: A systematic search was performed in PubMed, Google scholar, Cochrane Library, and EMBASE by two independent reviewers for comparative studies available till December 2017, with the primary objective to demonstrate a real lower dislocation rate of DMC implants compared to unipolar fixed-bearing cup designs. A meta-analysis was conducted with the collected pooled data about dislocation rate, calculating the risk difference (RD) and relative risk (RR) with 95% CI for dichotomous variables. Heterogeneity was tested using the χ2 and Higgins' I2 tests. A fixed-effect model was used because the statistical heterogeneity was below 50%.Results: After performing a critical exclusion process, the number of eligible studies included for final synthesis considered was 15, describing the results of a total of 2408 total hip arthroplasties (50.6% with a dual-mobility acetabular cup design, 49.4% with a standard fixed-bearing design). The fixed-effect meta-analysis showed a slight significant risk ratio of 0.16 (95% CI, 0.09, 0.28; I2 = 0%, p < 0.00001); a statistically significant difference in favor of the DMC group was maintained also considering only primary or revision arthroplasties, traumatic fractures or elective patients with diagnosis of osteoarthritis, avascular osteonecrosis or rheumatic arthritis.Conclusions: With the intrinsic limitations of our study design and based on the current available data, this study demonstrates that dual-mobility acetabular components decrease the risk of post-operative instability also in high-risk patients, both in primary and revision hip arthroplasties. However, new high-quality studies, possibly with a randomized control design, should be undertaken in order to strengthen the present data.Study Design: Level of Evidence III, therapeutic study. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the best surgical management of infected shoulder arthroplasty.Methods: A literature review from 1996 to 2016 identified 15 level IV studies that met inclusion criteria. Persistent infection (PI) was considered as treatment failure. Success was regarded as the absence of symptomatic PI without necessity for further treatment. Surgical outcomes were reported according to the mean weighted Constant and Murley score (CMS) for each treatment group.Results: Overall, 287 patients (146 males/141 females) were identified at a mean follow-up of 50.4 (range 32-99.6) months. The PI in the whole population was 11.5%. The pooled mean CMS, available for 218 patients, was 39 ± 13. Twenty-seven patients (9.4%) were treated with debridement (PI 29.6%, CMS 41 ± 12), 52 patients (18.1%) with resection arthroplasty (PI 11.5%, CMS 29 ± 16), 33 patients (11.5%) with permanent spacers (PI 6.1%, CMS 31 ± 14), 98 patients (34.2%) with two-stage revisions (PI 14.3%, CMS 42 ± 12) and 77 patients (26.8%) with one-stage revisions (PI 3.9%, CMS 49 ± 11). Debridement showed the highest PI rate (29.6%) and one-stage revisions reported the lowest PI rate (3.9%). Resection arthroplasty and spacers showed the poorest CMS when compared to the other procedures (p ≤ 0.0001). The debridement PI rate was significantly higher than almost any other procedure. CMS was significantly higher in patients undergoing revision compared to non-revision procedures (45 ± 12 vs. 35 ± 14) (p < 0.0001). One-stage revisions achieved significantly better results in terms of the PI rate compared to two-stage revisions (p = 0.0223), but not in terms of CMS.Conclusion: Debridement showed the highest PI rate (29.6%) and should not be recommended for the management of infected shoulder arthroplasty. Revisions reported better functional outcomes compared to non-revision procedures. The presence of a significantly lower PI rate with comparablely high mean CMS values suggests that one-stage (where technically applicable) could be superior to two-stage revisions. Unfortunately, well-designed randomized controlled trials using validated patient-based outcomes are lacking in this field.Level Of Evidence: Systematic Review of level IV studies, Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Despite the overall success of the surgical anterior cruciate ligament (ACL) reconstruction, some patients still present with instability symptoms even after the surgery, mainly due to the presence of associated lesions. At present, the pivot shift test has been reported to be the benchmark to assess rotatory knee laxity. The purpose of this study was to quantitatively evaluate rotatory knee laxity at time-zero in order to determine whether detected post-reconstruction laxity was predictable by its value measured before the reconstruction, which was hypothized to be influenced by the presence of associated lesions. Methods: Rotatory knee laxity was retrospectively analysed in 42 patients, including two different ACL reconstructions. The maximal anterior displacement and the absolute value of the posterior acceleration reached during the reduction of the tibial lateral compartment were intra-operatively acquired by using a navigation system and identified as discriminating parameters. For each parameter, statistical linear regression analysis (line slope and intercept) was performed between pre- and post-reconstruction values. Results: No statistically significant influence of the initial posterior acceleration on the post-reconstruction outcome was found (line slope, p > 0.05), although a statistically significant line intercept was indeed identified ( p < 0.001). A statistically significant influence on the surgery outcome was instead found for the initial value of the anterior tibial displacement (line slope = 0.39, p = 0.004), meaning that, on average, about 40 % of the post-reconstruction lateral compartment displacement could be explained by the corresponding pre-reconstruction value. Both of these findings highlighted the importance of intra-operative quantification of rotatory knee laxity to identify correct indications for the surgery. Conclusions: This study provided important implications for the future possibility of defining a quantifying tool able to assess rotatory knee laxity during ACL reconstruction. This could allow detection of additional injuries to secondary restraints by easily performing rotatory knee laxity tests, which in turn could reduce post-surgical recurrence of knee instability. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to evaluate the biomechanical results from the in vitro reconstruction of medial patellofemoral ligament (MPFL) using a navigation-assisted technique on a cadaveric model and its effects on patellar stability and kinematics. The authors investigated the hypothesis that patellar kinematics after reconstruction with a tubular graft are not optimal when compared with the original fan-shaped MPFL. Methods: In six fresh-frozen cadaveric knees, lateral loads (25 N) were applied on the patella at 0°, 30°, 60° and 90° of knee flexion in three different MPFL states: intact, cut and reconstructed. The arrangement allowed positional measurements of patellar motion to be tracked in six degrees of freedom. Medial to lateral patellar translation and patellar tilt were recorded. The kinematics after a technique of MPFL reconstruction, performed with a gracilis tendon in a blind femoral tunnel guided by navigation, were compared against kinematics recorded in the MPFL intact state. A temporary fixation of adequate tension to engage the lateral patellar facet in extension was applied to the MPFL and, after graft cycling, the final fixation was done at 70° knee flexion with an interference screw. Results: There was a comparable medial to lateral patellar translation and tilting of the patella in the MPFL-intact and the MPFL-reconstructed state. Static patellar translation in the MPFL-reconstructed state, with and without the application of load, was comparable to patellar translation in the MPFL-intact state. The dynamic patellofemoral shift kinematics recorded an under-constraint in early flexion and over-constraint in late flexion, while an opposite effect was recorded in patellar tilt. However, these differences were not statistically significant. Conclusion: The study confirmed the major role of the MPFL in case of medial loading between 0° and 60°, by focusing on the importance of kinematically identifying the proper femoral point for fixation. While the study demonstrates the importance of kinematic determination of the proper femoral point of fixation, as the anatomical insertion remains difficult to identify. Even in dissected cadavers, the authors recorded a slightly anterior placement than native MPFL. After reconstruction, patellar stability in terms of lateral translation and tilt was similar to the intact MPFL, but patellar kinematics were not optimal with the use of a smaller and tubular graft than the native wider and fan-shaped MPFL. [ABSTRACT FROM AUTHOR]