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Purpose: The purpose of this study was to evaluate the clinical outcomes of medial patellofemoral ligament (MPFL) reconstruction combined with derotational distal femur osteotomy in patients with recurrent patellar dislocation who had excessive femoral anteversion angle and trochlear dysplasia. Methods: Between 2015 and 2020, 64 patients (64 knees) with recurrent patellar dislocation, who had excessive femoral anteversion angle (≥ 25°) and trochlear dysplasia and were surgically treated using derotational distal femur osteotomy and MPFL reconstruction, were eligible for this retrospective study. These patients were assigned to two groups according to the grade of trochlear dysplasia. Group A (type A trochlear dysplasia, n = 33) and Group B (type B, C, D trochlear dysplasia, n = 31). Preoperative and postoperative patellar tilt angle (PTA), Caton–Deschamps index (CD-I), tibial tubercle–trochlear groove (TT–TG) distance and femoral anteversion angle were evaluated. Patient outcomes were assessed using the preoperative and postoperative International Knee Documentation Committee (IKDC) score, Kujala score, Lysholm score, Tegner score, and visual analog scale (VAS) score. Results: A total of 64 patients (64 knees) were evaluated in this study, with a mean follow-up period of 28.4 ± 3.6 months. There were no cases of wound infection, osteotomy site fractures, deep venous thrombosis of the lower extremities, or re-dislocation in the two groups during the postoperative follow-up period. All patients returned to full extension and flexion. The postoperative Tegner score, Lysholm score, Kujala score, IKDC score, VAS score, PTA, CD-I, TT–TG distance, and femoral anteversion angle were significantly improved compared with the preoperative status (P < 0.05). There was no significant difference between the two groups (n.s.). Conclusion: MPFL reconstruction combined with derotational distal femur osteotomy showed satisfactory clinical outcomes during follow-up in patients with recurrent patellar dislocation who had excessive femoral anteversion angle and trochlear dysplasia. Even patients with high-grade trochlear dysplasia showed satisfactory results. For those patients, additional surgery is not necessary. Level of evidence: Level III. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to present the existing literature relating to patient-reported outcome measures (PROMs) and complications in patients undergoing total knee arthroplasty (TKA) due to posttraumatic osteoarthritis (PTOA) with prior fracture treatment around the knee compared with patients who underwent TKA because of primary osteoarthritis (OA). Methods: A systematic review was undertaken and synthesised in accordance with the PRISMA guidelines by searching existing literature in the following databases: PubMed, Scopus, Cochrane Library and EMBASE. A search string according to the PECO was used. After analysing 2781 studies, 18 studies (5729 PTOA patients/149,843 OA patients) were included for a final review. An analysis revealed that 12 (67%) were retrospective cohort studies, four (22%) were register studies and the remaining two (11%) were prospective cohort studies. The mean Critical Appraisal Skills Programme (CASP) score was 23.6 out of 28, signifying studies of moderate quality. Results: The most frequently reported outcome measure were postoperative complications, reported in all eighteen studies. Intraoperative complications were reported in ten (4165 PTOA/124.511 OA) and patient-reported outcome measures (PROMs) in six studies (210 PTOA/2768 OA). A total of nine different PROMs were evaluated. As far as PROMs were concerned, the scores were inferior for PTOA but did not differ statistically from OA, except for one study, which favoured the OA group. Across all studies, postoperative complications were higher in the PTOA group, reporting infections as the most common complication. Furthermore, a higher revision rate was reported in the PTOA group. Conclusion: PROM analysis suggests that both patient groups benefit from a TKA in terms of functional outcome and pain relief, however, patient-reported outcomes could be inferior for PTOA patients. There is consistent evidence for increased complication rates following PTOA TKA. Patients undergoing TKA due to PTOA after fracture treatment should be informed about the risk for inferior results and refrain from comparing their knee function to patients with TKA after OA. Surgeons should be aware of the challenges that PTOA TKA poses. Level of evidence: Level III. [ABSTRACT FROM AUTHOR]

Purpose: Chondral injuries secondary to traumatic patella dislocation are common, and a subgroup of these are significant defects with fragments amenable to fixation. There is a paucity of published evidence assessing patients managed with combined acute patellofemoral stabilisation and osteochondral fixation. The purpose of this study is to report the outcomes of patients with osteochondral injuries secondary to acute traumatic patella dislocation treated with combined early fragment fixation and MPFL reconstruction using a quadriceps tendon turndown technique which has distinct advantages for this cohort, including preventing chondral overloading and non-violation of the patella bone. Methods: Patients who underwent combined quadriceps tendon MPFL reconstruction and osteochondral fixation were included. Patient demographics, defect characteristics, complications and reoperations were evaluated. Patients were assessed with Lysholm, Kujala, KOOS-PF scores and satisfaction scale at follow up. Pre-operative MRI was assessed for presence of radiological risk factors for patella dislocation and post-operative MRI was used to assess cartilage quality with MOCART 2.0 score. Results: A total of 19 patients (63.2% female) were included. The mean age was 17.4 ± 4.8 years and patients were followed up at a mean 15.8 ± 5.1 months post-surgery. The mean defect size was 2.4 cm2 ± 1.3 cm2, with the most common defect location being the patella (13/19; 68.4%) followed by the lateral femoral condyle (5/19; 26.3%). At final follow up, the overall mean Lysholm, Kujala, and KOOS-PF scores were 84.9 ± 11.1, 89.7 ± 5.8 and 80.6 ± 13.6, respectively. Seventeen patients (89.5%) were satisfied with their outcome. The mean MOCART 2.0 score at final follow-up was 72.5. One patient required medial capsular plication with removal of a loose chondral body and microfracture and 3 knees required minor reoperations. Conclusion: Combined acute osteochondral fragment fixation and MPFL reconstruction using a quadriceps tendon graft offers good radiological and patient-reported outcomes with high satisfaction and low rates of recurrent patella dislocation. To our knowledge, this is currently the largest series of its kind in the literature and the results of this study provide a rationale for a combined approach using a quadriceps tendon graft for this cohort. Level of evidence: Level IV. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to determine whether the flexion first balancing technique, developed in an attempt to solve the dissatisfaction due to instability in total knee arthroplasties, leads to better restoration of joint line height and medial posterior condylar offset. This might result in better knee flexion, compared to the classic extension first gap balancing technique. The secondary objective is to show non-inferiority of the flexion first balancing technique in terms of clinical outcomes as measured by the Patient Reported Outcome Measurements. Methods: A cohort of 40 patients (46 knee replacements) operated using the flexion first balancing technique was retrospectively analyzed and compared with a cohort of 51 patients (52 knee replacements) operated using the classic gap balancing technique. Radiographic analysis of the coronal alignment, joint line height and posterior condylar offset was performed. Clinical and functional outcome data were analyzed pre- and postoperatively and compared between both groups. The two sample t test, Mann–Whitney U test, Chi-square test and a linear mixed model were used for performing statistical analyses, after normality analyses were executed. Results: Radiologic evaluation showed a decrease in posterior condylar offset using the classic gap balancing technique (p = 0.040) versus no change using the flexion first balancing technique (p = n.s.). No statistically significant differences were noted for joint line height and coronal alignment. Using the flexion first balancer technique leads to a greater postoperative range of motion with deeper flexion (p = 0.002) and a better Knee injury and Osteoarthritis Outcome Score (KOOS) (p = 0.025). Conclusion: The Flexion First Balancing technique is a valid and safe technique for TKA, resulting in better preservation of PCO with consequently greater postoperative flexion and better KOOS scores. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: Trochlear dysplasia is an independent risk factor for recurrent patellar instability with evidence demonstrating its presence in up to 85% of patients with patellar instability. Severe trochlear dysplasia can be treated with trochleoplasty to improve engagement of the patella in the trochlear groove and prevent future dislocations. The aim of this study was to determine the clinical outcome of Bereiter trochleoplasty in patients with recurrent patellar instability and severe trochlear dysplasia. Methods: This was a retrospective case series of all trochleoplasties performed in our institution from 2008–2019. All clinical records and pre-operative MRI scans were reviewed to assess for trochlear dysplasia, tibial tuberosity to trochlear groove distance (TTTG) and patella height using patella trochlear index (PTI). Trochlear dysplasia was classified using Dejour classification. Incidence of re-dislocation, infection, arthrofibrosis, chondral necrosis and re-operation were recorded. All patients were invited to complete a post-operative visual analog score for pain (VAS-P) and Banff Patella Instability Instrument (BPII). Results: Fifty-eight trochleoplasties were performed in fifty patients during this period. All trochleoplasties were combined with additional procedures. 93% had concomitant medial patellofemoral ligament (MPFL) reconstructions and 47% had tibial tuberosity transfer. The mean follow-up period was 36.8 months. The rate of dislocation and arthrofibrosis were 5% each. There were no chondral necrosis or nonunion. The mean post-operative BPII was 58.4 and VAS-P was 30.4. Conclusions: Bereiter trochleoplasty, often combined with MPFL reconstruction and/or tibial tuberosity transfer results in low re-dislocation and complication rate. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Cemented fixation remains the gold standard in total knee arthroplasty. With an increasing number of younger patients undergoing total knee arthroplasty and a growing patient population demanding higher physical activity, a rising interest in discussion of cementless fixation is notable. The current scientific literature does not give a clear recommendation for or against uncemented total knee arthroplasty. The purpose of this study was the investigation of the 5-year clinical and radiographic outcomes of a cementless deep-dish rotating platform implant. Methods: A total of 91 primary cementless total knee arthroplasties were included in this single-centre prospective observational study. The primary outcome was revision rate due to aseptic component loosening. Further outcome measures were assessment of the of the radiographic outcome as well as the clinical outcome based on Range of Motion and scores such as American Knee Society Score, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score and European Quality of Life 5 Dimension 3 Level at a follow-up of 5 years. Results: Mean age of the study population was 67.3 ± 6.6 years with 49.5% of the participants being female. Aseptic component loosening occurred in none of the patients. Implant survival with revision for any reason as endpoint was 97.8% (95% CI 100–96%) and 95.6% (95% CI 100–94%) with reoperation of any cause as endpoint. Radiolucent lines were detected in a total of eight cases (8.8%) and disappeared within the first year after surgery in five cases. Total Range of Motion improved significantly from 106° ± 15° preoperatively to 118° ± 10° at final FU (p < 0.001). All investigated scores improved significantly after total knee arthroplasty. Conclusion: The results of this study reveal excellent mid-term performance of a cementless deep dish rotating platform total knee implant, with no component loosening, very low overall revision rate, only temporarily present radiolucent lines in a minority of patients and excellent clinical results. Therefore, cementless total knee arthroplasty is an appropriate treatment option for patients with severe osteoarthritis of the knee. Level of evidence: Level II (prospective cohort study). [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to assess tibial post-fracture between highly cross-linked polyethylene (HXPE) and conventional polyethylene inserts in consecutive posterior-stabilized (PS) total knee arthroplasty (TKA) over a minimum 12-year follow-up period. Methods: Between January 2007 and June 2008, a consecutive series of 2446 primary TKAs was performed in 1478 patients at a single institution. The final cohort was classified into two groups (1559 in the HXPE group and 887 in the conventional group) based on the insert material used during the procedure. Results: The mean follow-up period was 13.1 years in the HXPE group and 13.4 years in the conventional group. All 16 cases of tibial post-fracture occurred in the HXPE group. This complication rate was 1.03%. The mean elapsed time from primary TKA to the diagnosis of post-fracture was 3.9 years (range 0.5–10.0 years). Ten cases required replacement with a thicker polyethylene insert, and six cases underwent tibial revision surgery. There were no cases of tibial post-fracture in the conventional group. Conclusion: Tibial post-fracture is not a rare complication in PS TKA with HXPE. Therefore, the possibility of a tibial post-fracture should be considered if newly developed pain, acute subluxation, effusion, patellar clunking, or instability occurs in patients treated with PS Scorpio knee system TKA using an HXPE insert. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: The tibial stem fixation in an aseptic revision of total knee arthroplasty is poorly studied and controversial. The objective of this study was to prospectively compare clinical outcomes between hybrid and cemented fixation of the stem in aseptic tibial revision after a minimum follow-up of 5 years. Methods: Two sequential prospective cohorts of patients who underwent aseptic tibial revision were compared after a minimum follow-up of five years: 31 had both tibial tray and stem cemented (cemented group), and 42 had a hybrid fixation with tibial tray cemented and stem cementless (hybrid group). Clinical assessment was performed by the Knee Society Scores and reduced Western Ontario and McMaster Universities Arthritis Index. Radiological assessment was also performed. Results: There were no significant differences in preoperative data between groups. Postoperatively, no significant differences between groups in clinical scores or complication rate were found. Survival of the TKA revision at 5-year was 94% (95% CI 89–98%) in the cemented group, and 98% (95% CI 92–100%) in the hybrid group (ns). Conclusion: Clinical outcomes and implant survival were comparable between hybrid and cemented tibial stem fixation. Level of evidence: II. [ABSTRACT FROM AUTHOR]

Purpose: Identifying anatomical risk factors on recurrent dislocation after medial reefing is important for deciding surgical treatment. The present study aimed to retrospectively analyze the preoperative magnetic resonance imaging (MRI)-based parameters of patients treated with medial reefing and whether these parameters lead to a higher risk of recurrent dislocation. Methods: Fifty-five patients (18.6 ± 6.6 years) who underwent medial reefing after primary traumatic patellar dislocation (84% with medial patellofemoral ligament [MPFL] rupture) were included. Patients were followed up for at least 24 months postoperatively (3.8 ± 1.2 years) to assess the incidence of recurrent patellar dislocation. In patients without recurrent dislocation, the Kujala and subjective IKDC scores were assessed. Moreover, the tibial tubercle-trochlear groove (TT-TG), sulcus angle, patellar tilt, patellar shift, and lateral trochlea index (LTI) were measured. The patellar height was measured using the Caton-Dechamps (CDI), Blackburne-Peel (BPI), and Insall-Salvati index (ISI). The cohort was subclassified into two groups with and without recurrent dislocation. Differences between groups were analyzed with respect to the MRI parameters. Results: Forty percent had a pathological sulcus angle of > 145°, 7.2% had an LTI of < 11°, 47.3% had a patellar tilt of > 20°, and 36.4% had a TT-TG of ≥ 16 mm. Increased patellar height was observed in 34.5, 65.5, and 34.5% of the patients as per CDI, BPI, and ISI, respectively. Nineteen (34.5%) patients suffered from recurrent dislocation. Compared with patients without recurrent dislocation, those with recurrent dislocation had a significantly lower LTI (p = 0.0467). All other parameters were not significantly different between the groups. Risk factor analysis showed higher odds ratios (OR > 2), although not statistically significant, for MPFL rupture (OR 2.05 [95% confidence interval 0.38–11.03], LTI (6.6 [0.6–68.1]), TT-TG (2.9 [0.9–9.2]), and patellar height according to ISI (2.3 [0.7–7.5]) and CDI (2.3 [0.7–7.5])). Patients without recurrent dislocation had a Kujala score of 93.7 ± 12.1 (42–100) points and an IKDC score of 90.6 ± 11.7 (55.2–100) points. Conclusion: Anatomical, MRI-based parameters should be considered before indicating medial reefing. A ruptured MPFL, an LTI < 11°, a TT-TG ≥ 16 mm, a patellar tilt > 20 mm, and an increased patellar height according to ISI and CDI were found to be associated, although not significantly, with a higher risk (OR > 2) of recurrent patellar dislocation after medial reefing. Thorough preoperative analysis is crucial to reduce the risk of recurrent dislocation in young patient cohorts. Level of evidence: Level IV [ABSTRACT FROM AUTHOR]

Purpose: Humeral head resurfacing (HHR) is a less invasive, anatomic alternative to the conventional stemmed hemiarthroplasty in patients in whom isolated humeral head replacement is preferred. It was hypothesized that, in a mid-term cross-sectional subjective outcome analysis, HHR would have equivalent patient-reported and functional outcomes to stemmed hemiarthroplasty (HA).Methods: A total of 213 HHR and 153 HA procedures were performed at a single academic institution from 2000 to 2014. Of these, 106 HHR and 47 HA patients corresponding with 120 HHR and 55 HA shoulders responded to a survey that collected patient demographics, surgical outcomes, patient satisfaction, and self-reported range of motion scores using both bespoke and validated metrics.Results: Follow-up was longer in the HA group (9.4 ± 3.4 vs. 5.2 ± 1.8 years, p < 0.0001). Self-reported range of motion was equivalent between groups. Surgery was perceived as helpful following 76.7% of HHRs and 78.2% of HAs (p > 0.99). The ASES pain subscore was significantly worse in the HA group (25.2 ± 29.5 vs. 38.5 ± 12.7 after HHR, p < 0.0001), which translated into worse ASES total scores (45.1 ± 14.8 HA vs. 52.2 ± 23.7 HHR, p < 0.05). These findings were equivocal in responses received 2-8 years vs. ≥ 8 years after surgery.Conclusions: Indications should be equivocal; humeral head resurfacing is a viable alternative to hemiarthroplasty, with equivalent patient satisfaction and reduced pain in the mid-term post-operative period.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: With increasing incidence and indications for shoulder arthroplasty, there is an increasing emphasis on the ability to return to sports. The main goal of this study was to determine the rate of return to sport after shoulder arthroplasty.Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review and meta-analysis. A search was performed on MEDLINE, Scopus, EMBASE, and the Cochrane Library. The quality of the included studies was evaluated according to the Methodological Index for Nonrandomized Studies checklist. The main judgement outcome was the rate of return to sports activity after shoulder arthroplasty and the level of play upon return (identical or higher/lower level).Results: Thirteen studies were reviewed, including 944 patients (506 athletes), treated with shoulder arthroplasty at an average follow-up of 5.1 years (range, 0.5-12.6 years). The most common sports were swimming (n = 169), golf (n = 144), fitness sports (n = 71), and tennis (n = 63). The overall rate of return to sport was 85.1% (95% CI, 76.5-92.3%), including 72.3% (95% CI, 60.6-82.8%) returning to an equivalent or improved level of play, after 1-36 months. Patients undergoing anatomic total shoulder arthroplasty returned at a significantly higher rate (92.6%) compared to hemiarthroplasty (71.1%, p = 0.02) or reverse total shoulder arthroplasty (74.9%, p = 0.003).Conclusion: Most patients are able to return to one or more sports following shoulder arthroplasty, with anatomic total shoulder arthroplasty having the highest rate of return.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Osteonecrosis of the humeral head is a rare diagnosis. The aim of this systematic review was to identify published studies and analyse the best clinical evidence available related to the surgical management of osteonecrosis of the humeral head.Methods: A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. Published studies that reported the outcomes for adult patients treated surgically for osteonecrosis of the humeral head were included. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was followed.Results: Twelve studies were included: five prospective case series and seven retrospective case series. A total of 309 patients, comprising 382 shoulders, were included. Three main surgical procedures were evaluated: core decompression, hemi-arthroplasty and total shoulder arthroplasty.Conclusions: Based on the current available data, core decompression is a safe and effective option for treating low-grade osteonecrosis of the humeral head, while hemi-arthroplasty and total shoulder arthroplasty should be considered for high-grade osteonecrosis. More studies and better-designed trials are needed in order to enrich the evidence and enable researchers to draw stronger conclusions. Since osteonecrosis is an uncommon, though challenging disease, a proper knowledge of its treatment is needed.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: The UniCAP (®) implant for femoral resurfacing treatment of large cartilage lesions and early OA was introduced in 2006. The outcome of the present study is from a prospective cohort study of 64 patients, followed 2 years clinically and 7 years for revisions.Methods: From 2009 to 2013, 64 patients were treated with femoral resurfacing using the UniCAP implant. Indication for treatment with UniCAP implant was symptomatic huge cartilage lesion or early OA at the femoral condyle demonstrated by MRI or arthroscopy, which was ICRS grades 3-4 and more than 4 cm(2). There were 28 males and 36 females with a median age of 51 (range 35-65) years. Patients were followed for 2 years clinically with Knee Society subjective outcome scores (KSS), pain scores and radiographic evaluations and for 7 years with complications and reoperations.Results: At 2 years, the follow-up mean KSS improved from 49 (6.9) to 88 (17.1), the mean KSS function score improved from 46 (8.0) to 90 (17.1), and the mean Pain score improved from 7.4 (0.5) to 2.3 (1.4). 47 % of the implants were revised within 7 years to arthroplasty due to the progression of cartilage lesions, progressing of osteoarthritis or increased knee pain. The reoperation rate did not show any significant difference between females and males. The Kaplan-Meier survival rate was 50 % at 7 years, no difference among females and males.Conclusion: The present study demonstrated an improved subjective outcome and reduced pain after femoral resurfacing using the UniCAP (®) implant in a relatively large cohort of patients with symptomatic large cartilage lesions or early OA. A 47 % reoperation rate with conversion to arthroplasty was found. The femoral resurfacing implantation can be a temporary treatment for large cartilage lesions or early OA that is expected to develop into osteoarthritis. For younger patients who are ineligible for arthroplasty treatment, this implant can offer a temporary solution.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: There has been increasing interest in accelerated programs for knee arthroplasty. We examined the efficacy and safety of an outpatient surgery (OS) pathway in patients undergoing unicompartmental knee arthroplasty (UKA).Methods: This case-controlled study evaluates patients operated for UKA in an OS pathway (n = 20) compared to rapid recovery (RR), the current standard (n = 20). We investigated whether patients could be discharged on the day of surgery, resulting in comparable or better outcome by means of adverse events (AEs) in terms of pain (numerical rating scale, NRS), incidences of postoperative nausea and vomiting (PONV) and opiate use (<48 h postoperatively), complication and readmission rates (<3 months postoperatively). Patient-reported outcome measures (PROMS) were obtained preoperatively and 3 months postoperatively.Results: Postoperative pain (NRS > 5) was the most common reason for prolonged hospital stay in the OS pathway. Eighty-five per cent of the patients were discharged on the day of surgery, whereas 95 % of the patients were discharged on postoperative day 3 in the RR pathway. Overall, median pain scores in both pathways did not exceed a NRS score of 5, without significant differences (RR vs. OS) in the number of patients with PONV (4 vs. 2) and opiate use (11 vs. 9) <48 h postoperatively. At 3 months postoperatively, no significant differences were found for AEs and PROMS between both pathways.Conclusion: The results of this study illustrates that an OS pathway for UKA is effective and safe with acceptable clinical outcome. Well-established and adequate standardized protocols, inclusion and exclusion criteria and a change in mindset for both the patient and the multidisciplinary team are the key factors for the implementation of an OS pathway.Level Of Evidence: Case-control study, Level III. [ABSTRACT FROM AUTHOR]