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Joint line (JL) restoration is one of the major challenges in revision total knee arthroplasty (rTKA). There is debate regarding the most reliable methodology for the assessment of JL level during revision surgery. Among the strategies, the use of adductor tubercle (AT) as an anatomical landmark has been proposed. The purpose of this paper is to systematically review the available literature to understand the reliability of AT ratio to identify the JL, and the advantages and drawbacks of its application. A research was performed on the PubMed, Embase, Cochrane and Google Scholar databases based on the following inclusion criteria for articles' selection: (I) clinical reports of any level of evidence, (II) written in the English language, (III) published from 2010 to 2020, (IV) dealing with the use of the adductor tubercle as a landmark to restore JL in revision TKA. All relevant data were extracted by two independent investigators, and discrepancies were resolved by discussion and consensus. A total of 13 studies were included: nine were radiographic evaluations, 3 clinical reports and 1 was an ex-vivo study. Radiographic studies highlighted that AT is a landmark easy to identify, with high intra and inter-observer agreement, irrespective of gender, age and size of the patient. The comparison with other bony landmarks revealed superior reliability in favor of AT. Also during surgical procedures, AT can be safely located and some clinical studies confirmed that AT ratio helps surgeon in re-establishing a correct JL and achieve ligament balancing even in complex revision cases. AT is a reliable and easily detectable landmark, and AT ratio is a valid tool to determine the JL level and help surgeons to restore the JL and simultaneously achieve knee ligament balancing in r-TKA.

Purpose: To assess the return to sport rate of young professional athletes, to analyze their careers in terms of matches played and league participation over a minimum period of 6years after Meniscal Allograft Transplantation (MAT), as well as to assess the long-term clinical subjective outcomes and satisfaction. Methods: Thirteen professional athletes (ten soccer and one basketball players, one fencer and one wrestler) with a mean age at surgery of 23.4 ± 4.0 underwent MAT (six medial, seven lateral). The time required to return to sport, post-operative performance level and the number of reoperations were evaluated. At an average follow-up of 9.0 ± 2.8years, Lysholm, KOOS and Cincinnati scores were administered and collected. Results: Thirteen patients (100%) returned to sports practice after an average period of 11.8 ± 3.8months. Nine athletes (69%) returned to sports at the same pre-injury level. Overall, 93%, 85%, 62% and 55% were active until the 3rd, the 5th, the 7th and the 9th season after MAT, respectively. Seven patients (54%) underwent a reoperation after MAT, where only two of them (15%) were related to graft problems (one meniscectomy and one graft suture). Of the ten athletes that completed subjective evaluation, the mean Lysholm score was 72 ± 15 (0% “Excellent”, 10% “Good”, 60% “Fair”, 30% “Poor”). Of the athletes with lower scores, one suffered from patellar tendon rupture, one from post-operative infection and one from a previous femoral fracture. The mean Cincinnati knee score was 77 ± 18, while the average KOOS values were 60 ± 34 for sports. Conclusion: Meniscal Allograft Transplantation (MAT) in young professional athletes involved in strenuous activities allowed all patients to return to pre-injury sport and in nearly 70% of cases at their pre-injury level. After five seasons following MAT, 85% of patients were still active or playing more than 20–30 matches per season. On the other hand, nearly 50% underwent at least one reoperation and only 70% of patients were rated as “Good”, or “Fair” using the Lysholm score. Level of evidence: IV.

Objective To systematically review the available clinical evidence regarding the safety and efficacy of knee intraosseous injections for the treatment of bone marrow lesions in patients affected by knee osteoarthritis. Design A literature search was carried out on PubMed, Embase, and Google Scholar databases in January 2020. The following inclusion criteria were adopted: (1) studies of any level of evidence, dealing with subchondral injection of bone substitute materials and/or biologic agents; (2) studies with minimum 5 patients treated; and (3) studies with at least 6 months’ follow-up evaluation. All relevant data concerning clinical outcomes, adverse events, and rate of conversion to arthroplasty were extracted. Results A total of 12 studies were identified: 7 dealt with calcium phosphate administration, 3 with platelet-rich plasma, and 2 with bone marrow concentrate injection. Only 2 studies were randomized controlled trials, whereas 6 studies were prospective and the remaining 4 were retrospective. Studies included a total of 459 patients treated with intraosseous injections. Overall, only a few patients experienced adverse events and clinical improvement was documented in the majority of trial. The lack of any comparative evaluation versus subchondral drilling alone is the main limitation of the available evidence. Conclusions Knee intraosseous injections are a minimally invasive and safe procedure to address subchondral bone damage in osteoarthritic patients. They are able to provide beneficial effects at short-term evaluation. More high-quality evidence is needed to confirm their potential and to identify the best product to adopt in clinical practice.

Purpose This study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopaedic and trauma surgery training in Europe by conducting an online survey among orthopaedic trainees. Methods The survey was conducted among members of the Federation of Orthopaedic and Trauma Trainees in Europe (FORTE). It consisted of 24 questions (single-answer, multiple-answer, Likert scales). Orthopaedic trainees’ demographic data (six questions), clinical role changes (four questions), institutional changes due to the COVID-19 pandemic (nine questions), and personal considerations (five questions) were examined. Results Three hundred and twenty-seven trainees from 23 European countries completed the survey. Most trainees retained their customary clinical role (59.8%), but a significant number was redeployed to COVID-19 units (20.9%). A drastic workload decrease during the pandemic was reported at most institutions. Only essential activities were performed at 57.1% of institutions and drastic disruptions were reported at 36.0%. Of the respondents, 52.1% stated that faculty-led education was restricted and 46.3% pursued self-guided learning, while 58.6% stated that surgical training was significantly impaired. Concerns about the achievement of annual training goals were expressed by 58.2% of the participants, while 25.0% anticipated the need for an additional year of training. Conclusions The SARS-CoV-2 pandemic significantly affected orthopaedic and trauma training in Europe. Most trainees felt the decrease in clinical, surgical, and educational activities would have a detrimental effect on their training. Many of them consulted remote learning options to compensate training impairment, stating that after the COVID-19 pandemic electronic educational approaches may become more relevant in future. Electronic supplementary material The online version of this article (10.1007/s00264-020-04742-3) contains supplementary material, which is available to authorized users.

Prosthetic joint infection (PJI) management is not standardized worldwide and the outcome is frequently unsatisfactory. More and more arthroplasties are now being performed. An increasing number of highly virulent and antibiotic-resistant bacteria and an ageing population of patients presenting with many comorbidities make it necessary to focus on this important topic. Diagnosis of PJI remains challenging because the clinical signs and symptoms and elevation of systemic biomarkers (C-reactive protein, erythrocyte sedimentation rate) may be unclear. In the last few years, the clinical research has focused on synovial fluid biomarkers as a possible breakthrough in the complex scenario of PJI diagnosis. Synovial biomarkers have shown encouraging results and they should be used as diagnostic adjuncts to synovial white cell count and culture bacteriology. Synovial leukocyte esterase (LE) and synovial C-reactive protein (CRP) have been evaluated as good screening measures; however, the most promising synovial fluid biomarker in terms of sensitivity and specificity for PJI seems to be alpha defensin (AD). The laboratory-based alpha defensin enzyme-linked immunosorbent assay (ELISA) test demonstrated the highest ever reported accuracy for PJI diagnosis. However, an alpha defensin lateral flow test could have its place in ruling in a suspected PJI intraoperatively because of its high specificity and rapid results.Cite this article: EFORT Open Rev 2019;4:10-13. DOI: 10.1302/2058-5241.4.180029

Correct component alignment in total knee arthroplasty (TKA) is crucial for implant functionality and longevity. Several devices have been developed to help surgeons to achieve optimal component positioning. The purpose of our study was to evaluate the accuracy and reliability of a novel inertial-based cutting guide used to perform tibial resection in TKA taking into account users with different levels of experience.Seven operators (raters) with different levels of experience participated in the study. To evaluate the accuracy, the varus/valgus (VV) and slope (SL) angles obtained with this novel device were compared with the reference angles obtained with the navigation system. To calculate intra-(rater) reliability repeated measurements of VV and SL angles by the same operator were used. To calculate inter-(rater) reliability repeated measurements of VV and SL by different operators were used.A total of 140 acquisitions were performed. In this study both for the VV and for the SL the maximum mean absolute error (MAE) that the inertial system registered was1°. Intra-inter reliability was evaluated by calculating the Fleiss' Kappa coefficient, which recorded values close to 0.75 (75%) with regard to the VV and the SL for intra-reliability, while values were recorded around 0.9 (90%) for the inter subject reliability.The Perseus system is accurate, reliable and surgeon-friendly and could be very useful in improving results in low-volume centers.

Purpose The purpose of the present study was to investigate if the donor age of nonirradiated Achilles tendon allograft could influence the clinical results of revision anterior cruciate ligament (ACL) reconstruction. Methods All patients that underwent ACL revision between 2004 and 2008 with at least 4 years of follow-up were included. For all the patients that met the inclusion criteria, the age of the graft donor was obtained from the tissue bank. Lysholm score was administered to patients that met inclusion criteria. In addition, patients were divided in two groups based on the donor age ( Results Fifty-two patients were evaluated at a mean 4.8 ± 0.8 years follow-up with Lysholm score. The Lysholm significantly improved from 62.3 ± 6.6 at preoperative status to 84.4 ± 12.3 at final follow-up. The mean donor age was 48.7 ± 8.4 years; a significant difference in Lysholm score was noted between patients that received an allograft with a donor age Conclusion Donor age of nonirradiated Achilles tendon allograft influenced the mid-term results of revision ACL reconstruction, thus advising the use of grafts from young donors. Level of Evidence Level III, retrospective comparative study.

Purpose The purpose of this study was to compare, in terms of blood loss and implant alignment, a new generation of smart extramedullary (EM) cutting guides with the conventional intramedullary (IM) guide for total knee arthroplasty (TKA). The hypothesis was that the EM system would result in less blood loss and fewer days of hospitalization, while ensuring equal or higher accuracy in the alignment of the femoral implant. Methods Thirty-six patients were enrolled for the present study: 18 patients underwent TKA using the EM guide and for the other 18 patients the IM guide was used. Preoperative and postoperative X-rays were acquired. The preoperative and postoperative hemoglobin values were compared. Lastly, length of hospital stay was recorded. Results The hemoglobin difference was significantly lower in the EM group. The alignment of the prosthetic femoral implant in the two groups was comparable but all patients in the EM cohort had a final alignment within 3 degrees of range on the frontal view, while 22% of the patients in the IM cohort had a final alignment exceeding 3 degrees of range. The mean hospitalization duration showed no significant difference between groups, though EM group showed 1.6 days less compared with IM group. Conclusions The inertial-based EM guide system could be useful for decreasing blood loss compared with conventional guide. This device tended to have better results even in terms of accuracy, but this difference was not significant. Level of Evidence This is a level II, prospective cohort study.

Purpose: To quantitatively evaluate the biomechanical sealing function of an intact labrum and the effect of labral–chondral separation, cerclage suture labral repair, vertical mattress suture repair and partial labrectomy on distraction load and hip joint centre (HJC) displacement. Methods: Eight fresh-frozen cadaveric hips were tested using a navigation system for intra-operative kinematic analysis. A six-axis load cell was used to measure the manually applied force when performing the tests: hip pivoting movement and distraction. The HJC displacement that occurred during the distraction test has been evaluated in correspondence of seven different values of applied force. During the pivoting motion, the maximum value of HJC displacement was evaluated. Five different conditions were tested: labrum intact, labral–chondral separation, vertical mattress suture repair, cerclage suture repair, and partial labrectomy. Results: With regard to HJC displacement using at fixed value of force, the paired sample t test underscored the statistically significant differences (p < 0.05) for each of the five tested conditions among themselves. Only the comparison of intact versus labral–chondral separation was not significantly different. During pivoting motion, a statistically significantly greater displacement was identified after labrectomy when compared with the cerclage suture repair (p = 0.03) and vertical mattress repair (p < 0.01) in medial–lateral direction. Along proximal—distal direction, a significant lower displacement after labrectomy was identified when compared to the cerclage suture repair (p = 0.03). Performing the pivoting motion at the extreme ranges of motion demonstrated a higher value of displacement after labrectomy when compared with all the previously tested conditions. Conclusions: These results suggest that labral repair is important in the function of the hip and that the vertical mattress suture technique may be better than the cerclage suture repair.

Purpose: To quantify the influence of ALL lesions on static and dynamic laxity in ACL-deficient knee. Methods: The study was performed in 10 fresh-frozen knees. The joints were analysed in the following conditions: intact, ACL resection and ACL+ALL resection. Testing parameters were defined as: anterior displacement at 30° and 90° of flexion (AP30, AP90) applying a manual-maximum load; internal rotation at 30° and 90° of flexion (INT30, INT90) applying a 5Nm torque and internal rotation and acceleration during manual pivot-shift (PS) test. Kinematics was acquired by a navigation system; a testing rig and a torquemeter were used to control the limb position and the applied torque. Paired Student’s t test was conducted to assess statistical difference, and significance was set at P&nbsp

PURPOSE: Combinations of intra- and extra-articular procedures have been proposed for anterior cruciate ligament reconstruction with the aim of achieving an optimal control of translational and rotational knee laxities. Recently, the need for better reproducing the structural and functional behavior of the native anterior cruciate ligament led to the definition of anatomic double-bundle surgical approach. This study aimed to quantitatively verify whether the in vivo static and dynamic behavior obtained using over-the-top single-bundle with extra-articular tenodesis reconstruction was comparable to the results achieved by anatomic double-bundle approach. METHODS: Thirty-five consecutive patients, with an isolated anterior cruciate ligament injury, were included in the study. Standard clinical laxities and pivot-shift test were quantified before and after anterior cruciate ligament reconstruction by means of a surgical navigation system dedicated to kinematic assessment; displacements of medial and lateral compartment during stress tests were also analyzed. RESULTS: Single-bundle with extra-articular tenodesis approach presented statistically better laxity reduction in varus/valgus stress test at full extension and in internal/external rotation at 90° of flexion; lateral plasty controlled better the lateral compartment during drawer test and varus/valgus stress test both at 0° and 30° of flexion and both the compartments during internal/external rotation at 90° of flexion. On the other hand, pivot-shift phenomenon was better controlled by anatomic double-bundle reconstruction. CONCLUSIONS: Both the reconstructions worked similarly for static knee laxity. The extra-articular procedure played an important role in better constraining the displacement of lateral tibial compartment, whereas the anatomic double-bundle reconstruction better restored the dynamic behavior of knee joint highlighted under pivot-shift stress test. STUDY DESIGN: Case series.

The hypothesis was that an alteration of different surgical variables of ACL reconstruction would produce significant changes in post-operative static laxity of knee joint. Joint laxity was acquired by a surgical navigation system for 17 patients just after graft fixation during single-bundle reconstruction with extra-articular lateral tenodesis. The analysed laxity parameters were: internal/external rotation at 30° (IE30) and 90° (IE90) of flexion, varus/valgus rotation at 0° (VV0) and 30° (VV30) of flexion and anterior/posterior displacement at 30° (AP30) and 90° (AP90) of flexion. As surgical variables, the angles between the tibial tunnel and the three planes were defined as well as the lengths of the tunnel and the relationship between native footprints and tunnels. The same analysis was performed for the femoral side. All surgical variables were combined in a multivariate analysis to assess for predictive factors between them and post-operative laxities values. To quantify the performance of each multivariate model, the correlation ratio (η 2) and the corresponding P value (*P

Meniscal tears are the most common knee injuries, with a reported annual incidence of 61 per 100,000 people [1]. For years meniscectomy has been considered the gold standard treatment for meniscal lesions, due to the lack of knowledge regarding the role of the meniscus and the long-term effects of its deficiency. In fact nowadays, it is well known that even partial deficiency of the meniscus could be destructive for knee joint at long term. It is reported that meniscectomy increases the risk of developing knee osteoarthritis after 10 years of about 20 % for medial meniscus and 40 % for lateral meniscus [2] (Fig. 26.1). This is due to its important and irreplaceable functions, such as increasing congruity of the joint, reducing contact stresses, shock absorption, stabilization, proprioception, and cartilage lubrification and nutrition [3, 4]. For these reasons the management of meniscal tears changed dramatically over the years, from aggressive toward more conservative strategies. In this background meniscal substitution with allograft and more recently with scaffolds has been proposed in case of irreparable lesions.

in this chapter the most frequent sports - related knee pathologies are described.A detailed description of clinical presentation , diagnostic behaviour, prevention and tretment options are presented for cruciate and collateral legament, meniscus and cartilage injuries.

PURPOSE: Although traditionally not indicated for the treatment of osteoarthritis (OA), regenerative procedures are becoming a focus of increased interest due to their potential to provide pain relief and alter the progression of degenerative diseases. The purpose of this study was to assess whether a combined biomechanical and biological approach could offer good results in unicompartmental OA, thus delaying the need for unicompartmental arthroplasty in patients too young or refusing metal resurfacing. METHODS: Forty-three patients (mean age = 40.1 ± 11 years, 33 men and 10 women, mean BMI = 25 ± 3) affected by unicompartmental OA (Kellegren-Lawrence score = 3) in stable joints were enrolled and treated consecutively. Fifteen patients were treated with osteotomy and osteochondral biomimetic scaffold implant (3 of them also with meniscal substitution), 11 with osteotomy and meniscal scaffold implant, 9 with osteotomy and meniscal allograft implant, and 8 with both cartilage and meniscal reconstruction, depending on the specific joint compartment main requirements. Clinical evaluation was performed at 3-year (2-4) median follow-up using the following scoring systems: IKDC subjective and objective, VAS for pain, and Tegner scores. Failures, adverse events, and complications were also reported. RESULTS: The IKDC subjective score improved from 47.3 to 79.6 at the final evaluation (p < 0.0005), VAS improved from 6.1 to 2.3 (p < 0.0005), and also sport activity level evaluated with the Tegner score showed a significant improvement, from 2 (1-5) to 4 (3-10; p < 0.0005), even if without achieving the pre-injury level (6, p = 0.001). A further subanalysis confirmed the positive outcome obtained in all the treatment subgroups and showed a higher clinical improvement in patients under the age of 40 years (IKDC subjective 84.4 ± 13.2 vs 76.5 ± 17.3; p = 0.03). CONCLUSION: This integrated biological and biomechanical approach produced a marked improvement at short-medium follow-up in patients affected by unicompartmental OA. Even though a good outcome was achieved at all ages, patients under the age of 40 years presented a greater clinical and subjective improvement. Longer follow-up studies are needed to show results over time and confirm this approach as an effective alternative to unicompartmental implants.

Abbiamo dimostrato in un precedente studio che i pazienti con lesioni combinate del legamento crociato anteriore (LCA) e del legamento collaterale mediale (LCM) presentano simili lassità in antero-posteriore (AP), ma un maggiore valgo a 30° di flessione dopo la ricostruzione del LCA, rispetto ai pazienti che hanno subito una ricostruzione isolata di del LCA. Il presente studio ha valutato la stessa coorte di pazienti ad un minimo di tre anni di follow-up per valutare se la lassità residua in valgo abbia portato a peggiori risultati clinici. Ogni paziente ha subito una ricostruzione artroscopica a doppio-fascio del LCA utilizzando un innesto di semitendinoso-gracile. Nella gruppo LCA/LCM, la lesione di II grado del legamento collaterale mediale non è stata trattata. Al follow-up, la lassità in AP è stata misurata utilizzando un artrometro KT-2000, mentre la lassità in valgo è stata valutata mediante radiografia e Telos, confrontando l’arto operato con il ginocchio illeso. Abbiamo valutato i punteggi dei risultati clinici ottenuti, della circonferenza muscolare e il tempo necessario al ritorno in attività per i due gruppi. Le radiografie con stress in valgo hanno mostrato una maggiore differenza statistica nell’apertura mediale del gruppo LCA/LCM rispetto all’arto sano (1,7 mm (SD 0,9) rispetto a 0,9 mm (SD 0,7), rispettivamente, p = 0,013), mentre nessuna differenza statisticamente significativa è stata rilevata nelle lassità in AP e negli altri parametri clinici. I nostri risultati mostrano che la lassità residua in valgo non influisce in modo significativo ad un minimo di follow-up di tre anni, il che suggerisce che nessuna procedura chirurgica aggiuntiva è necessaria per il trattamento del legamento collaterale mediale nelle lesioni combinate.

Purpose Benefits of an early reconstruction and the optimal time lapse between injury and surgery to reduce the effects of altered kinematics in ACL-deficient knees are still controversial. Aim The aim of this study was to clarify, through a quantitative in vivo evaluation, the effects of the time lapse between ACL injury and surgery in terms of changes in the pre-operative knee laxity. Methods An in vivo study was performed on 99 patients who underwent ACL surgery. Just before the graft fixation, six laxity tests were performed for all the subjects at manual-maximum load: anterior–posterior displacement and internal–external rotation at 30° and 90° of knee flexion (AP30, AP90, IE30, IE90) as well as varus–valgus rotation (VV0, VV30) at 0° and 30° of flexion. Kinematics data were acquired by a navigation system. The Spearman rank correlation was used to assess correlation between rank and continuous data. Significance was set at P = 0.05. Results The analysis highlighted a significant influence of the injury-to-surgery time lapse on VV0 and AP90 compared with pre-operative laxity levels. Meniscus status also significantly affected the pre-operative laxity in the VV0 (Spearman's ρ = 0.203, P = 0.038; GLM with meniscal correction partial η = 0.27, P = 0.007) and AP90 (Spearman's ρ = 0.329, P = 0.001; GLM with meniscal correction partial η = 0.318, P = 0.017) tests. Conclusion The main finding of this study is that patients with ACL rupture and a higher injury-to-surgery time present higher values of knee laxity involving AP90 displacement and VV30 rotation. Clinical relevance of the study is that ACL-deficient joint laxity, involving anterior–posterior displacement at 90° of knee flexion and varus–valgus rotation at 0° of flexion, is significantly affected by the lapse of injury-to-surgery time. This highlights the importance of considering the effects of delaying surgery when managing patients with such deficiency.

This book provides a comprehensive guide to the evaluation, treatment, and rehabilitation of musculoskeletal injuries commonly experienced by football (soccer) players. It will be of particular value for orthopedists and sports medicine practitioners, and will provide the information required by trainers and medical staff regarding the traumatic lesions associated with the sport. It is also anticipated that the book will assist in reducing the risk of trauma in footballers. The new edition has been revised to reflect advances in knowledge and practice and will be more valuable than ever, given that the risk of trauma continues to increase owing to the intensity and speed of modern football, the current training methods, and technical and tactical innovations. Injuries are a major adverse event during a footballer’s career, and they require appropriate medical and/or surgical treatment and rehabilitation. The overviews provided in this book will help in delivering such care.

recent years, research studies into sports injuries have provided healthcare professionals with a better understanding of their etiology and natural history. On this basis, novel concepts in the diagnosis and management of these conditions are now being explored. This timely book offers a complete guide to the latest knowledge on the diagnosis and treatment of the full range of possible sports injuries. Individual sections are devoted to biomechanics, injury prevention, and the still emerging treatment role of growth factors, which foster more rapid tissue healing. Sports injuries of each body region are then examined in detail, with special attention to diagnostic issues and the most modern treatment techniques. In addition, pediatric sports injuries, extreme sports injuries, the role of physiotherapy, and future developments are extensively discussed. All who are involved in the care of patients with sports injuries will find this textbook to be an invaluable, comprehensive, and up-to-date reference.

Le meniscectomie parziali artroscopiche hanno mostrato migliori risultati clinici rispetto alla rimozione completa del menisco, ma a lungo termine un numero consistente di questi pazienti subiscono l'effetto degenerativo della perdita della cartilagine meniscale. Infatti è estremamente importante preservare il menisco per quanto possibile, al fine di evitare la progressiva degenerazione del ginocchio. Durante gli anni ’80 Stone, Steadman e Rodkey hanno sviluppato un nuovo scaffold in collagene per sostituire il menisco in caso di rotture parziali/subtotali irreparabili: il CMI (Collagen Meniscus Implant). Dopo 13 anni di buoni risultati nell’impianto del CMI mediale, nel 2006 abbiamo iniziato uno studio postmarketing per valutare l'efficacia e la sicurezza di uno scaffold meniscale equivalente appositamente costruito per riparare il menisco laterale (CMI laterale). In questo articolo descriviamo le indicazioni per l'impianto di un dispositivo CMI, l'evoluzione della tecnica chirurgica (da una tecnica di sutura artroscopia “in-out” ad una “all-inside”) in questi 13 anni di esperienza insieme ad una breve relazione sui nostri risultati clinici.