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Purpose: The aim of the study was to evaluate the long-term clinical results, reoperations, surgical failure and complications at a minimum of 20 year of follow-up of the first 8 medial CMI scaffolds implanted by a single surgeon during a pilot European Prospective study. Methods: Seven (88%) out of 8 patients were contacted. The Cincinnati Score, VAS, and Lysholm score were collected. Moreover, magnetic resonance imaging (MRI) was performed on 4 patients at the last follow-up. Complications, reoperations and failures were also investigated. Results: The average follow-up was 21.5 ± 0.5 years. One patient underwent TKA after 13 years from CMI implantation; a second patient underwent valgus high tibial osteotomy 8 years after the index surgery and another patient underwent anterior cruciate ligament hardware removal at 21 years of follow-up. At the final follow-up, 3 patients were rated as "Excellent", 1 as "Good" and 2 as "Fair" according to the Lysholm score. The Cincinnati score and the VAS were substantially stable over time. The MRI showed a mild osteoarthritis progression in 3 out of 4 patients according to the Yulish score, and the CMI signal was similar to the mid-term follow-up revealing 3 cases of myxoid degeneration and 1 case of normal signal with reduced scaffold size. Conclusion: The medial CMI is a safe procedure: satisfactory clinical results and a low failure rate could be expected even at a long-term follow-up. For this purpose, the correct indication as well as correcting axial malalignment and addressing knee instability at the time of the index surgery is mandatory. On the other hand, a mild osteoarthritis progression could be expected even after meniscus replacement. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Subchondral bone is becoming a treatment target for knee OA patients, with promising early findings on the use of bone marrow aspirate concentrate (BMAC). The aim of this prospective, multi-centric pilot study was to evaluate safety as well as clinical and MRI outcomes of a combined approach of intra-articular and subchondral BMAC injections. Methods: Thirty patients (19 men, 11 women, 56.4 ± 8.1 years) with symptomatic knee OA were treated with a combination of an intra-articular and two subchondral BMAC injections (femoral condyle and tibial plateau). Patients were evaluated at baseline and at 1–3–6–12 months of follow-up with the IKDC subjective, VAS, KOOS, and EQ-VAS scores. The MRI evaluation was performed with the WORMS score. Results: No major complications were reported and only two patients were considered treatment failures, requiring a new injective or surgical treatment. The IKDC subjective score improved significantly from 40.5 ± 12.5 to 59.9 ± 16.1 at 3 months, 59.1 ± 12.2 at 6 months, and 62.6 ± 19.4 at 12 months (p < 0.0005). A similar improvement was reported for VAS pain and all KOOS subscales at all follow-ups, while EQ-VAS did not show any significant improvement. The MRI analysis showed a significant bone marrow edema reduction (p = 0.003), while the remaining WORMS parameters did not show any significant changes. Conclusion: The pilot evaluation of this combined BMAC injective treatment showed safety and positive outcome up to 12 months of follow-up in patients with symptomatic knee OA associated with subchondral bone alterations. These findings suggest that targeting both subchondral bone and joint environment can provide promising results, and that BMAC can be a valid option for this combined approach to treat knee OA. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the present study was to trace knee position at the time of bone bruise (BB) and investigate how much this position departed from the knee biomechanics of an in vivo flexion–extension. Methods: From an original cohort of 62 patients, seven (11%) presented bicompartmental edemas and were included in the study. 3D models of bones and BB were obtained from MRI. Matching bone edemas, a reconstruction of the knee at the moment of BB was obtained. For the same patients, knee kinematics of a squat was calculated using dynamic Roentgen sterephotogrammetric analysis (RSA). Data describing knee position at the moment of BB were compared to kinematics of the same knee extrapolated from RSA system. Results: Knee positions at the moment of BB was significantly different from the kinematics of the squat. In particular, all the patients' positions were out of squat range for both anterior and proximal tibial translation, varus–valgus rotation (five in valgus and two in varus), tibial internal–external rotation (all but one, five externally and one internally). A direct comparison at same flexion angle between knee at the moment of BB (average 46.1° ± 3.8°) and knee during squat confirmed that tibia in the former was significantly more anterior (p < 0.0001), more externally rotated (6.1 ± 3.7°, p = 0.04), and valgus (4.1 ± 2.4°, p = 0.03). Conclusion: Knee position at the moment of Bone bruise position was out of physiological in-vivo knee range of motion and could reflect a locked anterior subluxation occurring in the late phase of ACL injury rather than the mechanism leading to ligament failure. Level of evidence: Level IV [ABSTRACT FROM AUTHOR]

Purpose: Aim of the study is to assess the contribution of peri-articular soft tissues to hip joint kinematics and their influence on hip stability. Methods: Four hemi-corpse specimens (3 males, average age 72 years) were studied using a custom navigation system. Hip kinematics (femoral head motion relative to the acetabulum and joint range of motion) were evaluated with the hip manually positioned in 36 different positions with (I) soft tissues intact, (II) after removal of the skin and muscles and (III) after partial capsulectomy. Each position was repeated 3 times in each state. Results: Excellent interclass correlation for each test was determined (ICC range, 0.84-0.96). Femoral head anatomical centre displacement relative to the acetabulum occurred in all 3 planes, even with all the soft tissue intact (average, 3.3 ± 2.8 mm lateral translation; 1.4 ± 1.8 mm posterior translation and 0.3 ± 1.5 mm distally). These translations increased as more soft tissue was removed, except medial-lateral displacement, with an average 4.6 ± 2.9 mm lateral translation, 0.7 ± 1.3 mm posterior translation and 1.5 ± 1.9 mm distal translation when partial capsulectomy was performed. Range of motion increased in all 3 planes with increasing removal of the soft tissues. Conclusions: This study showed that femoral head anatomical centre displacement within the acetabulum occurs and increases with increasing removal of peri-articular soft tissues, confirming their influence on hip stability. Hip kinematics was also influenced by peri-articular soft tissues; specifically range of motion increases with increasing removal of those tissues. From clinicians' point of view, they have therefore to consider the influence of their surgeries on peri-articular soft tissues, since excessive translations may promote hip arthritis. [ABSTRACT FROM AUTHOR]

In this article, we discuss current topics for rotatory knee laxity. All tests for knee laxity have a value. Static knee laxity tests reveal information for each individual patient's laxity status, especially compared to the contralateral side. Static knee laxity tests are simple to do, and some of them are instrumented, therefore quantifiable. Dynamic knee laxity tests are more complex. Dynamic stereo radiography (DSX) is considered the gold standard. Utilizing DSX, information can be gained on 3-D kinematics, functional joint space, and joint contact patterns. The disadvantage is that DSX is expensive and can only be performed in a laboratory environment. The pivot shift test is a unique test, because it is dynamic and easily performed in the office. However, it is subjective and only recently quantifiable. Future endeavors will attempt to improve the value of the pivot shift test by standardizing the test and improving measurement technologies, while keeping the pivot shift test simple and non-invasive. [ABSTRACT FROM AUTHOR]

The treatment of segmental tibial and ankle bone loss after radical surgery for chronic osteomyelitis is one of the most challenging problems encountered by orthopaedic surgeons. Open tibia and ankle fractures occur with an incidence of 3.4 per 100,000 and 1.6 per 100,000, respectively [[1]] and have a high propensity to lead to the development of fracture-related infection with associated chronic osteomyelitis. However, compared to the more commonly used technique of bone transport with external fixation, no complications (including non-union, stress, or refracture at the bone regeneration site or pin tract infections) have been observed. [Extracted from the article]

The article aims to describe an arthroscopic-assisted surgical technique for focal resurfacing of the medial tibiofemoral compartment and offer a preliminary clinical and radiographic results in a case series of 13 patients at mean follow-up of 29 months. It notes that to date, minimally invasive surgery (MIS) for unicompartmental knee replacement (UKR) has been based on limited incision. The study is indicated as the first report on a case series of patients treated with an arthroscopic-assisted focal resurfacing of the medial tibiofemoral compartment.

Purpose: The purpose of this study is to describe an arthroscopic-assisted surgical technique for focal resurfacing of medial tibio-femoral compartment and to present the preliminary clinical and radiographic results in a case series of 13 consecutive patients at a mean follow-up of 29 months. Methods: All patients were treated with the presented procedure for Ahlback grade 3 medial compartment osteoarthritis. Subjective evaluation was based on a visual analog scale for pain self-assessment. Objective clinical evaluation was based on Hospital for Special Surgery score. Range of motion was evaluated with a manual goniometer. Radiographic evaluation compared hip-knee-ankle angle pre- and post-operatively. Results: Clinical and functional results were satisfactory. Hospital for Special Surgery score and visual analog scale for pain self-assessment showed significant improvements ( P < 0.0001 and P = 0.0002, respectively). ROM and axial alignment were not significantly different respect to pre-operative values. Conclusions: Despite the small sample size and short follow-up, this study has shown that an arthroscopic-assisted focal resurfacing of the knee in selected cases can be a viable option for early onset degenerative joint disease, providing satisfactory pain relief and good functional results at 2 years follow-up. Level of evidence: Retrospective case series, Level IV. [ABSTRACT FROM AUTHOR]

Background: The hip joint center is a fundamental landmark in the identification of lower limb mechanical axis; errors in its location lead to substantial inaccuracies both in joint reconstruction and in gait analysis. Actually in Computer Aided Surgery functional non-invasive procedures have been tested in identifying this landmark, but an anatomical validation is scarcely discussed. Methods: A navigation system was used to acquire data on eight cadaveric hips. Pivoting functional maneuver and hip joint anatomy were analyzed. Two functional methods – both with and without using the pelvic tracker – were evaluated: specifically a sphere fit method and a transformation techniques. The positions of the estimated centers with respect to the anatomical center of the femoral head, the influence of this deviation on the kinematic assessment and on the identification of femoral mechanical axis were analyzed. Findings: We found that the implemented transformation technique was the most reliable estimation of hip joint center, introducing a – Mean (SD) – difference of 1.6 (2.7) mm from the anatomical center with the pelvic tracker, whereas sphere fit method without it demonstrated the lowest accuracy with 25.2 (18.9) mm of deviation. Otherwise both the methods reported similar accuracy (<3mm of deviation). Interpretation: The functional estimations resulted in the best case to be in an average of less than 2mm from the anatomical center, which corresponds to angular deviations of the femoral mechanical axis smaller than 1.7 (1.3)° and negligible errors in kinematic assessment of angular displacements. [Copyright &y& Elsevier]

Surgical navigation systems are currently used to guide the surgeon in the correct alignment of the implant. The aim of this study was to expand the use of navigation systems by proposing a surgical protocol for intraoperative kinematics evaluations during knee arthroplasty. The protocol was evaluated on 20 patients, half undergoing unicondylar knee arthroplasty (UKA) and half undergoing posterior-substituting, rotating-platform total knee arthroplasty (TKA). The protocol includes a simple acquisition procedure and an original elaboration methodology. Kinematic tests were performed before and after surgery and included varus/valgus stress at 0 and 30° and passive range of motion. Both UKA and TKA improved varus/valgus stability in extension and preserved the total magnitude of screw-home motion during flexion. Moreover, compared to preoperative conditions, values assumed by tibial axial rotation during flexion in TKA knees were more similar to the rotating patterns of UKA knees. The analysis of the anteroposterior displacement of the knee compartments confirmed that the two prostheses did not produce medial pivoting, but achieved a postoperative normal behavior. These results demonstrated that proposed intraoperative kinematics evaluations by a navigation system provided new information on the functional outcome of the reconstruction useful to restore knee kinematics during surgery. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:202-207, 2009 [ABSTRACT FROM AUTHOR]

El tratamiento de las lesiones del cartílago articular sigue siendo un reto para el médico. Aunque los resultados del implante de condrocitos autólogos parecen favorables a corto y medio plazo, se están destinando recursos a la investigación para mejorar la tecnología. Un campo prometedor de investigación es la unión de condrocitos cultivados con andamios. Los médicos clínicos quieren técnicas que se puedan implantar fácilmente, que reduzcan la morbilidad quirúrgica, que no requieran recogida de otros tejidos, que exhiban mejor proliferación y maduración celular, que mantengan más fácilmente el fenotipo y que permitan una completa y eficaz integración en el cartílago articular circundante. Las características que hacen que un andamio sea óptimo para su uso clínico son que sea biocompatible, biodegradable, permeable, reproducible, mecánicamente estable, no citotóxico y capaz de servir como sostén transitorio a las células mientras permite la sustitución ocasional por los componentes de la matriz sintetizados por las células implantadas. Cada vez hay más experiencia clínica con las técnicas de reparación del cartílago basadas en tres andamios, cada uno de los cuales es de un material diferente: implante de condrocitos autólogos inducidos por la matriz, andamio a base de ácido hialurónico y malla de polímero de una mezcla de ácido poliláctico/poliglicólico. Los resultados clínicos son esperanzadores. La futura dirección de la reparación del cartílago con andamios se dirige a los que son bioactivos y con orientación espacial. [ABSTRACT FROM AUTHOR]

A biodegradable, hyaluronian-based biocompatible scaffold was used for autologous chondrocyte transplantation. This prospective study analyzes a clinical outcome of 70 consecutive patients treated by arthroscopic autologous chondrocyte transplantation at minimum 24 months follow up (47 of these patients achieved minimum 36 months follow-up and 21 patients minimum 48 months follow-up) in order to establish clear indication criteria for this type of treatment. 31 of these patients presented isolated chondral lesions, while 39 patients with associated lesions (23 ACL lesions, 28 meniscal lesions, 1 varus knee) were treated during the same surgical procedure with cartilage harvesting. A statistically significant clinical improvement was shown just at 24 months and the second-look arthroscopy demonstrated a complete coverage of the grafted area with a hyaline cartilage-like tissue in 12 of 15 analyzed patients. A better clinical outcome was observed in young, well-trained patients and in traumatic lesions. Other factors, such as defect size, localization, previous and associated surgery did not influence significantly the results. This matrix autologous chondrocyte transplantation procedure simplifies the surgical procedure and can be performed arthroscopically, thus reducing surgical morbidity and recovery time. [ABSTRACT FROM AUTHOR]

A biodegradable, hyaluronian-based biocompatible scaffold was used for autologous chondrocyte transplantation. This prospective study analyzes a clinical outcome of 70 consecutive patients treated by arthroscopic autologous chondrocyte transplantation at minimum 24 months follow up (47 of these patients achieved minimum 36 months follow-up and 21 patients minimum 48 months follow-up) in order to establish clear indication criteria for this type of treatment. 31 of these patients presented isolated chondral lesions, while 39 patients with associated lesions (23 ACL lesions, 28 meniscal lesions, 1 varus knee) were treated during the same surgical procedure with cartilage harvesting. A statistically significant clinical improvement was shown just at 24 months and the second-look arthroscopy demonstrated a complete coverage of the grafted area with a hyaline cartilage-like tissue in 12 of 15 analyzed patients. A better clinical outcome was observed in young, well-trained patients and in traumatic lesions. Other factors, such as defect size, localization, previous and associated surgery did not influence significantly the results. This matrix autologous chondrocyte transplantation procedure simplifies the surgical procedure and can be performed arthroscopically, thus reducing surgical morbidity and recovery time. [ABSTRACT FROM AUTHOR]

Background: Locked posterior glenohumeral dislocations with a reverse Hill-Sachs impaction fracture involving less than 30% of the humeral head are most frequently treated with lesser tuberosity transfer into the defect, whereas those involving more than 50% undergo humeral head arthroplasty. Reconstruction of the defect with segmental femoral osteochondral allografts has been proposed to treat patients between these two ranges, but the medium-/long-term outcomes of this joint-preserving procedure are controversial.Methods: Between 2001 and 2018, 12 consecutive patients with a unilateral locked posterior shoulder dislocation and an impaction fracture from 30 to 50% (mean 31% ± 1.32) of the humeral head were treated with segmental reconstruction of the defect with fresh-frozen humeral head osteochondral allografts. Patients were assessed clinically, radiographically and with computed tomography (CT) at a medium follow-up of 66 ± 50.25 months (range, 24-225).Results: All twelve shoulders presented a slight limitation in anterior elevation (average, 166.6° ± 22.76). The mean active external rotation with the shoulder at 90° of abduction was 82.5° ± 6.61, and that with the arm held in stable adduction was 79.16 ± 18.80. The mean abduction was 156.25° ± 25.09. The mean Constant-Murley score (CS) was 82 ± 15.09 points (range, 40-97 points), and the mean ASES was 94 ± 8.49 points. The mean pre- and postoperatively Western Ontario Shoulder Instability index (WOSI) was 236.5 ± 227.9 and 11.20 ± 10.85, respectively. Development of osteoarthrosis (OA) was minimal. The average allograft resorption rate was 4% ± 2.4. There were no cases of failure (reoperation for any reason) in this series.Conclusion: Segmental humeral head reconstruction with humeral head fresh-frozen osteochondral allografts provides good to excellent clinical results with low-grade OA and low allograft resorption in patients with locked posterior shoulder dislocation.Trial Registration: ClinicalTrials.gov PRS, ClinicalTrials.gov ID: NCT04823455 . Registered 29 March 2021 - Retrospectively registered, https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000AU8P&selectaction=Edit&uid=U0004J36&ts=12&cx=6cykp8 LEVEL OF EVIDENCE: Level IV, Case Series, Treatment Study. [ABSTRACT FROM AUTHOR]

Purpose: To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique. Methods: A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three. Results: Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction. Conclusion: A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification. Level of evidence: Level V. [ABSTRACT FROM AUTHOR]

Background: Cell-free devices have been introduced to restore osteochondral defects, avoiding the limitations of cell-based procedures. Among these, an osteochondral scaffold made of type I collagen and hydroxyapatite has been investigated with promising results up to medium-term follow-up. However, the clinical and imaging results over time still need to be documented. Purpose: To evaluate the clinical outcome and tissue maturation at long-term follow-up after the implantation of the osteochondral scaffold. Study Design: Case series; Level of evidence, 4. Methods: A total of 24 patients (7 women, 17 men; age, 36 ± 9.5 years) underwent surgical implantation of the osteochondral scaffold and were prospectively evaluated before surgery, at 2-, 5-, and 10-year follow-up. The mean defect size was 2.9 ± 1.4 cm2. Patients were evaluated using the International Knee Documentation Committee (IKDC) subjective and objective scores, and the activity level was documented with the Tegner score. Magnetic resonance imaging (MRI) evaluation involved the use of the magnetic resonance observation of cartilage repair tissue score combined with 5 more variables focused on the bone layer. Results: A statistically significant improvement of all clinical scores was documented from the baseline to the final evaluation. The IKDC subjective score improved from the preoperative level to 2 years (41 ± 13.2 and 77.1 ± 14.6, respectively) (P <.0005), with stable results up to 10 years (77.4 ± 19.4). The IKDC objective score changed from 52% of normal and nearly normal knees before the treatment to 84% at 10 years (P <.0005). Tegner sports activity at the final evaluation (3.8 ± 1.7) was higher compared with the preoperative level (1.6 ± 1.1; P <.05), but it remained significantly lower compared with the preinjury level (5.5 ± 2.6; P <.05). Treatment failed in 1 patient. Persisting graft alterations were observed on MRI scans, although without correlating with the clinical outcome. Conclusion: The regenerative potential of this scaffold is limited, as demonstrated by the signal alterations persisting over time on MRI scans. On the other hand, the clinical improvement was significant and stable over time both in terms of subjective and objective outcomes, including activity level, with overall good results. [ABSTRACT FROM AUTHOR]

• Femur and tooth were the most investigated bone segments. • A bonded bone-implant interface was used in about half of the studies. • 3D simulations were predominantly used. • The bone remodeling function proposed by Huiskes et al. (1987) was used in more than half of the retrieved studies. • The change in bone density was the most investigated outcome. The aim of the present study was to review the literature concerning the analysis of periprosthetic bone remodeling through finite element (FE) simulation. A systematic review was conducted on 9 databases, taking into account a ten-year time period (from 2009 until 2020). The inclusion criteria were: articles published in English, publication date after 2009, full text articles, articles containing the keywords both in the abstract and in the title. The articles were classified through the following parameters: dimensionality of the simulation, modelling of the bone-prosthesis interface, output parameters, type of simulated prosthesis, bone remodeling algorithm. Sixty-seven articles were included in the study. Femur and tooth were the most evaluated bone segment (respectively 41.8% and 29.9%). The 55.2% of the evaluated articles used a bonded bone-prosthesis interface, 73% used 3D simulations, 67.2% of the articles (45 articles) evaluate the bone remodeling by the bone density variation. At last, 59.7% of the articles employed algorithms based on a specific remodeling function. Increasing interest in the bone remodeling FE analysis in different bone segments emerged from the review, and heterogeneous solutions were adopted. An optimal balance between computational cost and accuracy is needed to accurately simulate the bone remodeling phenomenon in the post-operative period. [ABSTRACT FROM AUTHOR]

The anterolateral ligament (ALL) has been suggested as an important secondary knee restrain on the dynamic laxity in anterior cruciate ligament- (ACL-) deficient knees. Nevertheless, its kinematical contribution to the pivot-shift (PS) phenomenon has not been clearly and objectively defined, and noninvasive sensor technology could give a crucial contribution in this direction. The aim of the present study was to quantify in vitro the PS phenomenon in order to investigate the differences between an ACL-deficient knee and an ACL+ALL-deficient knee. Ten fresh-frozen paired human cadaveric knees (n = 20) were included in this controlled laboratory study. Intact, ACL-deficient, and ACL+ALL-deficient knees were subjected to a manual PS test quantified by a noninvasive triaxial accelerometer (KiRA, OrthoKey). Kinematic data (i.e., posterior acceleration of the tibial lateral compartment) were recorded and compared among the three statuses. Pairwise Student's t -test was used to compare the single groups (p < 0.05). Intact knees, ACL-deficient knees, and ACL+ALL-deficient knees showed an acceleration of 5.3 ± 2.1 m/s2, 6.3 ± 2.3 m/s2, and 7.8 ± 2.1 m/s2, respectively. Combined sectioning of ACL and ALL resulted in a statistically significant acceleration increase compared to both the intact state (p < 0.01) and the ACL-deficient state (p < 0.01). The acceleration increase determined by isolated ACL resection compared to the intact state was not statistically significant (p > 0.05). The ALL sectioning increased the rotatory laxity during the PS after ACL sectioning as measured through a user-friendly, noninvasive triaxial accelerometer. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to describe the sagittal geometry of the trochlear groove in patients who underwent primary TKA, based on intraoperative data acquired with a navigation system.Methods: Intraoperative navigation data were collected from 110 patients. All operations were guided by a non-image-based navigation system (BLU-IGS, Orthokey Italia Srl). The trochlear groove has been described on the three anatomical planes; in particular, on the sagittal plane the hypothesis has been verified that the acquired points are referable to a circle. Using the data collected during intraoperative navigation, possible correlation between the radius of the trochlear groove and other femur dimension (length, AP dimension) was analyzed; the orientation of the trochlear sulcus with respect to the mechanical axis and the posterior condyle axis was analyzed too, searching for possible correlation between groove alignment (frontal and axial) or groove radius and the hip-knee-ankle (HKA).Results: The average radius of curvature of the femoral trochlea was 25.5 ± 5.6 mm; the difference was not statistically significant between the men and women (n.s. p value). No correlation was found between the trochlear groove radius and the femur length (r = - 0.02) or the HKA-phenotypes (r = 0.03) and between the groove alignment and HKA-phenotypes. On axial plane, the trochlear groove was 3.2° ± 4.3° externally rotated, with respect to the posterior condylar axis; on frontal plane, the trochlear groove was 3.9° ± 5.3° externally rotated, with respect to the mechanical axis. In both cases, no statistically significant differences were found between male and female and between left and right limb (p > 0.05).Conclusion: The present study shows that the sagittal plane geometry of the femoral trochlea in patients affected by osteoarthritis could be described accurately as a circle. The acquisition of the trochlear morphology intraoperatively can lead to more anatomically shape definition, to investigate deeper its radius of curvature and geometry. Trochlear shape could be used as landmarks for femoral component positioning, thus customizing the implant design, optimize the outcomes and improving anterior knee pain after TKA.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: To document clinical and radiological results of arthroscopic matrix-assisted autologous chondrocyte transplantation (MACT) combined with bone grafting for the treatment of knee osteochondritis dissecans (OCD) at long-term follow-up. Methods: Thirty-one knees in 29 patients (20.4 ± 5.7 years) were treated for symptomatic unfixable OCD lesions (2.6 ± 1.1 cm2) and prospectively evaluated at 2, 5, and 12 years (average, minimum 10 years). Patients were evaluated over time with IKDC subjective score, EQ-VAS, and Tegner scores. Failures were also documented. At the final follow-up, MRI evaluation was performed in 14 knees with the MOCART 2.0 score. Results: Beside 4 early failures, an overall clinical improvement was documented: the IKDC subjective score improved from 39.9 ± 16.8 to 82.1 ± 17.0 and 84.8 ± 17.2 at 2 and 5 years, respectively (p < 0.0005), and remained stable for up to 12 years (85.0 ± 20.2). EQ-VAS and Tegner scores presented similar trends, but patients did not reach their original activity level. Worse results were obtained for lesions bigger than 4 cm2. At MRI evaluation, subchondral bone abnormalities were detected in over 85% of knees at long-term follow-up. Conclusions: Arthroscopic bone grafting followed by MACT for unfixable knee OCD can offer a promising and stable clinical outcome over time in lesions smaller than 4 cm2, with a low failure rate of 13%. Persistent subchondral alterations were documented at long-term MRI evaluation, suggesting the limits of this approach to regenerate the osteochondral unit in patients affected by knee OCD. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: To assess the role of Tibial Plateau Slope (TPS) as risk factor for early Anterior Cruciate Ligament (ACL) reconstruction failure and contralateral ACL injury in a population of patients with less than 18 years of age and operated on with the same surgical technique. Methods: Ninety-four consecutive patients (mean age 15.7 ± 1.5 years) with at least 2 years of follow-up, who underwent ACL reconstruction with a single-bundle plus lateral-plasty hamstring technique in the same centre were included. Subsequent ACL injuries (ipsilateral ACL revision or contralateral ACL reconstruction) were assessed within the first 2 years after surgery. Anterior, central, posterior TPS of medial compartment were measured on lateral radiographs and compared between patients with intact graft and those with a second injury. Cut-off values with sensitivity and specificity were calculated with receiver operating characteristic (ROC) analysis. Survival analysis for second ACL injuries and multivariate analysis were performed. Results: Eight patients (9%) had ipsilateral ACL Revision and eight patients (9%) had contralateral ACL reconstruction. Patients with contralateral injury had a higher Central TPS with respect to those without second injury (12.6° ± 2.8° vs 9.3° ± 3.7°, p = 0.042). No differences were present in patients with ipsilateral ACL revision. Sensitivity and specificity for central TPS slope ≥ 12° to detect a contralateral rupture were 63% and 75% (p = 0.0092), for Anterior TPS were 100% and 52% (p = 0.0009). Patients with TPS values exceeding these cut-offs had higher rate of contralateral ACL injuries (19%vs4%, p = 0.0420) and lower 2-year survival (p = 0.0049). Multivariate analysis identified pre-operative sport level and TPS (either anterior or central) as risk factors for contralateral injuries. Conclusions: Steep tibial plateau slope ≥ 12° is associated with a higher risk of contralateral ACL injury within 2 years after ACL reconstruction in patients less than 18 years of age. However, TPS has no role in early ipsilateral re-injury after combined ACL reconstruction and lateral plasty. The clinical relevance is that both the surgeon and the patient should be aware of this higher risk and consider it in the rehabilitation phase to reduce the incidence of such injuries. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Introduction: Injuries involving the tarsometatarsal (TMT) joint are relatively uncommon, and the surgical treatment is potentially characterized by a high complications rate. The purpose of this study is to evaluate the results of the treatment of Lisfranc fracture-dislocations treated with closed reduction and percutaneous fixation with K-wires, considering complications and re-intervantion rate.Materials and Methods: A retrospective review was performed on all patients undergone closed reduction and percutaneous fixation with K-wires of a Lisfranc fracture-dislocation. Patients have been clinically evaluated at last follow up by American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Visual Analogue Scale (VAS), as well as by radiograph assessment.Results: Following inclusion and exclusion criteria, 15 patients have been included, with a mean age of 48.2 ± 5.6 years. Average follow-up was 3.8 ± 1.8 years (range 1-6). 7 fractures analyzed were classified as type A, 7 as type B (3 were B1, 4 were B2) and 1 as type C1. No case of loss of reduction has been observed at radiographic 1-month follow-up. At last follow-up mean AOFAS midfoot score and VAS score were respectively 82.2 ± 10.4 and 1.5 ± 1.3. Registered complications showed one deep vein thrombosis and 2 cases of complex regional pain syndrome (CRPS). One patient subsequently underwent arthrodesis of the tarsometatarsal joint for post-traumatic arthritis.Conclusions: The treatment of the fracture-dislocations of the Lisfranc joint by percutaneous reduction and fixation with K-wire can achieve good clinical outcomes with a low rate of complications and reoperations.Level Of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the author discusses various reports within the issues on topics including patellofemoral (PF) disorders and new techniques for diagnosis and treatment of the disorders.

Purpose: The aim of this study was to evaluate the efficacy of a new minimally invasive surgical technique for the reconstruction of the medial patellofemoral ligament (MPFL) with fascia lata allograft at 60-month minimum follow-up. Methods: Nineteen consecutive patients with chronic recurrent patellar dislocation were treated with MPFL reconstruction (53% isolate procedure, 47% in combination with other treatments). Seventeen patients (11 males/6 females) were available at 60-month follow-up and were clinically evaluated with validated scores. New episodes of patellar dislocation were considered failures. Radiographic and CT scan evaluation were executed preoperatively and at 60-month follow-up. Results: All clinical scores improved from preoperative assessment to 24-month and 60-month follow-up (p < 0.001). Kujala score increased from 61.2 ± 18.1 to 86.7 ± 8.7 and 82.1 ± 10.2; KOOS increased from 54.5 ± 19 to 86.8 ± 9.6 and 84.3 ± 7.6; VAS for pain decreased from 5.1 ± 2.2 to 2.4 ± 1.5 and 1.7 ± 1.2; Tegner score increased from 3 [2–4] to 5 [3–8] and 5 [3–9], respectively. Objective IKDC improved too. No significant improvements between the 24-month and 60-month follow-up evaluations were recorded. Anterior knee pain was reported in two patients (12%). Treatment failure, a new episode of patellar dislocation 25 months after the surgery, was observed in one patient (6%). Radiographic OA changes were not statistically significant between preop and 60-month follow-up. Tuberosity-troclear groove (TT-TG) distance and the patellar tilt angle were subjected to significant changes due to MPFL reconstruction and associated procedures. Conclusion: MPFL reconstruction with fascia lata allograft, alone or combined with other procedures, is a reliable treatment option for recurrent patellar dislocation with a success rate of 94% and without cartilage deterioration at 60-month follow-up. Level of evidence: IV [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to report on a worldwide web-based survey among the ESSKA community developed to investigate current recommendations regarding ACL reconstruction surgical procedures. Methods: All contacts in the official mailing list of the ESSKA were contacted to investigate preferences regarding graft type, anterolateral ligament reconstruction, femoral tunnel drilling technique, single-bundle vs double-bundle technique, femoral and tibial fixation methods. Results: Eight-hundred and twenty responses were analyzed. Hamstrings autograft was the graft of choice in male patients for 634 (79%) and in female patients for 674 (84%) responders, while its preference for ACL reconstruction in professional athletes was for 401 (50%). 480 (63%) surgeons surveyed would include anterolateral ligament reconstruction only if diagnosed and remaining instability after ACL surgery or revision. 598 (75%) respondents were in favor of anteromedial portal for femoral tunnel drilling. The most popular femoral fixation technique was found to be cortical suspension (500–66%), while a compression system was preferred on the tibial side by 537 (71% of the sample). Conclusions: This survey study found that HT autograft, single-bundle reconstruction, anteromedial portal for femoral tunnel drilling, cortical suspension systems for femoral fixation and compression systems for tibial fixation represent the current standard of ACLR in a large community of orthopedic surgeons. The present study performed with surgeons who are members of the ESSKA community will help to comprehend the actual ACLR worldwide practice patterns. Due to low response rate, these results should be interpreted with caution and not to be intended to represent the state of the art of ESSKA community. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Background: The lateral femoral notch sign (LNS) is a bony impression on the lateral femoral condyle correlated with anterior cruciate ligament (ACL) injury. Its presence is associated with lateral meniscal injury and higher cartilage degradation on the lateral femoral condyle. Purpose/Hypothesis: The purpose was to investigate the effect of the presence and magnitude of LNS on rotatory instability. The hypothesis was that a positive LNS is correlated with a high-grade pivot shift (PS). Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 90 consecutive patients with complete ACL tears between 2013 and 2017 underwent intraoperative kinematic evaluation with the surgical navigation system and were included in the present study. The same surgeon performed a standardized PS under anesthesia. The PS was quantified through the acceleration of the lateral compartment during tibial reduction (PS ACC) and the internal-external rotation (PS IE). Presence and depth of LNS were evaluated on sagittal magnetic resonance images (1.5-T). Results: In 47 patients, the LNS was absent; in 33, the LNS depth was between 1 mm and 2 mm; and in 10 patients, it was deeper than 2 mm. Patients with a notch deeper than 2 mm showed increased PS ACC and PS IE compared with the group without the LNS. However, no significant differences were present between the group with a notch between 1 and 2 mm and the patients without LNS. Receiver operating characteristic curve analysis showed that 2 mm was the most predictive cutoff value to identify the "high-grade rotatory instability" group, with an accuracy of 77.8% and 74.4% and a specificity of 95.5% and 93.9% referred to the PS ACC and PS IE, respectively. Conclusion: The presence of a lateral LNS deeper than 2 mm could be used for the preoperative identification of patients with a high risk of increased rotatory instability. [ABSTRACT FROM AUTHOR]

Purpose: The role of the anterior cruciate ligament (ACL) in knee biomechanics in vivo and under weight-bearing is still unclear. The purpose of this study was to compare the tibiofemoral kinematics of ACL-deficient knees to healthy contralateral ones during the execution of weight-bearing activities. Methods: Eight patients with isolated ACL injury and healthy contralateral knees were included in the study. Patients were asked to perform a single step forward and a single leg squat first with the injured knee and then with the contralateral one. Knee motion was determined using a validated model-based tracking process that matched subject-specific MRI bone models to dynamic biplane radiographic images, under the principles of Roentgen stereophotogrammetric analysis (RSA). Data processing was performed in a specific software developed in Matlab. Results: Statistically significant differences (p < 0.05) were found for single leg squat along the frontal plane: ACL-deficient knees showed a more varus angle, especially at the highest knee flexion angles (40°–50° on average), compared to the contralateral knees. Furthermore, ACL-deficient knees showed tibial medialization along the entire task, while contralateral knees were always laterally aligned. This difference became statistically relevant (p < 0.05) for knee flexion angles included between 0° and about 30°. Conclusion: ACL-deficient knees showed an abnormal tibial medialization and increased varus angle during single leg squat when compared to the contralateral knees. These biomechanical anomalies could cause a different force distribution on tibial plateau, explaining the higher risk of early osteoarthritis in ACL deficiency. The clinical relevance of this study is that also safe activities used in ACL rehabilitation protocols are significantly altered in ACL deficiency. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate if there was a correlation between in vivo kinematics of a medial-stabilized (MS) total knee arthroplasty (TKA) and post-operative clinical scores. We hypothesized that (1) a MS-TKA would produce a medial pivot movement and that (2) this specific pattern would be correlated with higher clinical scores.Methods: 18 patients were evaluated through clinical and functional scores evaluation (Knee Society Score clinical and functional, Womac, Oxford), and kinematically through dynamic radiostereometric analysis (RSA) at 9 months after MS-TKA, during the execution of a sit-to-stand and a lunge motor task. The anteroposterior (AP) Low Point translation of medial and lateral femoral compartments was compared through Student's t test (p < 0.05). A correlation analysis between scores and kinematics was performed through the Pearson's correlation coefficient r.Results: A significantly greater (p < 0.0001) anterior translation of the lateral compartment with respect to the medial one was found in both sit-to-stand (medial 2.9 mm ± 0.7 mm, lateral 7.1 mm ± 0.6 mm) and lunge (medial 5.3 mm ± 0.9 mm, lateral 10.9 mm ± 0.7 mm) motor tasks, thus resulting in a medial pivot pattern in about 70% of patients. Significant positive correlation in sit-to-stand was found between the peak of AP translation in the lateral compartment and clinical scores (r = 0.59 for Knee Society Score clinical and r = 0.61 for Oxford). Moreover, we found that the higher peak of AP translation of the medial compartment correlated with lower clinical scores (r = - 0.55 for Knee Society Score clinical, r = - 0.61 for Womac and r = - 0.53 for Oxford) in the lunge. A negative correlation was found between Knee Society Score clinical and VV laxity during sit-to-stand (r = - 0.56) and peak of external rotation in the lunge motor task (r = - 0.66).Conclusions: The MS-TKA investigated produced in vivo a medial pivot movement in about 70% of patients in both examined motor tasks. There was a correlation between the presence of medial pivot and higher post-operative scores.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique. Methods: Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the "Graft" was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The "Tibial Tunnel" was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0–10. Tunnel and graft positioning were evaluated. Results: At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months (p = 0.008) and 18-months (p = 0.028), the tunnel was significantly smaller (p < 0.05) and less enlarged at both follow-ups (p < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months (p < 0.05). The total score of the non-detached group saw a significant improvement at 4-months (p = 0.006) that remained stable at 18-months (n.s.). Conclusions: Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient. Level of evidence: IV. [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]

Background: Long-term patient-reported outcome measures (PROMs) and predictors of success or failure after anterior cruciate ligament (ACL) reconstruction are not fully understood, especially when combined with a lateral extra-articular reconstruction. Purpose: To assess the long-term PROMs, revision rate, and predictors of success or failure after ACL reconstructions using an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular reconstruction. Study Design: Case series; Level of evidence, 4. Methods: The study cohort consisted of 267 consecutive patients (mean age, 30.7 years) who underwent ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular augmentation between November 2007 and May 2009. The number of subsequent ACL revisions and reoperations were recorded. Subjective clinical status was assessed with PROMs—specifically, the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and visual analog scale for pain—at a minimum follow-up of 10 years. Results: Overall, 3% of patients underwent ACL revision, with a 10-year survival rate of 96.3%. High sport activity (hazard ratio, 6.9; P =.285) and concomitant meniscal lesion (hazard ratio, 2.6; P =.0487) were predictors of ACL revision or new meniscectomy. The mean ± SD Lysholm score was 94.1 ± 10.8, while that for the visual analog scale for pain was 0.2 ± 0.9 at rest and 2.1 ± 2.6 during activity. KOOS subscale scores were as follows: 95.7 ± 8.1 for Pain, 92.5 ± 10.5 for Symptoms, 98.4 ± 7.4 for Activities of Daily Living, 90.7 ± 17.2 for Sport, and 91.2 ± 17.1 for Quality of Life; respectively, 88%, 99%, 81%, 89%, and 91% of patients achieved the Patient Acceptable Symptom State. Female sex and chondropathy with Outerbridge grade ≥2 were predictors of worse KOOS subscales. Overall, 82% of patients returned to sport, and 57% were still participating at the 10-year evaluation. Conclusion: ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring autografts and a lateral extra-articular reconstruction provided satisfactory results in terms of function, symptoms, sports, and quality of life in 80% to 90% of patients after 10 years. Long-term survivorship was 96%. Sport participation declined from 82% postoperatively to 57% at long-term follow-up. A concomitant medial meniscal lesion was a predictor of higher risk of ACL failure or new meniscal lesion, while advanced chondropathy and female sex were predictors of higher pain, lower function, and poor quality of life scores. [ABSTRACT FROM AUTHOR]

Objective. Tranexamic acid (TXA) is increasingly used in orthopedic surgery to reduce blood loss; however, there are concerns about the risk of venous thromboembolic (VTE) complications. The aim of this study was to evaluate TXA safety in patients undergoing lower limb orthopedic surgical procedures. Design. A meta-analysis was performed on the PubMed, Web of Science, and Cochrane Library databases in January 2020 using the following string (Tranexamic acid) AND ((knee) OR (hip) OR (ankle) OR (lower limb)) to identify RCTs about TXA use in patients undergoing every kind of lower limb surgical orthopedic procedures, with IV, IA, or oral administration, and compared with a control arm to quantify the VTE complication rates. Results. A total of 140 articles documenting 9,067 patients receiving TXA were identified. Specifically, 82 studies focused on TKA, 41 on THA, and 17 on other surgeries, including anterior cruciate ligament reconstruction, intertrochanteric fractures, and meniscectomies. The intravenous TXA administration protocol was studied in 111 articles, the intra-articular in 45, and the oral one in 7 articles. No differences in terms of thromboembolic complications were detected between the TXA and control groups neither in the overall population (2.4% and 2.8%, respectively) nor in any subgroup based on the surgical procedure and TXA administration route. Conclusions. There is an increasing interest in TXA use, which has been recently broadened from the most common joint replacement procedures to the other types of surgeries. Overall, TXA did not increase the risk of VTE complications, regardless of the administration route, thus supporting the safety of using TXA for lower limb orthopedic surgical procedures. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this study was to compare the risk of periprosthetic infection of a consecutive cohort of primary varus–valgus constrained (VVC) total knee arthroplasties (TKAs), with a matched 1:1 cohort of primary posterior-stabilized (PS) TKAs. Methods: 74 primary VVC TKAs performed in 66 patients were identified and matched 1:1 with a cohort of 74 primary PS TKAs performed in 73 patients. At last follow up, patients were clinically evaluated using the Knee Society Score (KSS). Kaplan–Meier survival curves were generated to analyze survivorship using as endpoints revision for any reason, revision for periprosthetic infection and revision for mechanical failure after excluding periprosthetic infection. A multivariate logistic regression analysis was constructed to determine whether revision surgery for periprosthetic infection was influenced by patients' gender, age, surgical time and reasons for TKA (primary vs secondary osteoarthritis). Results: Demographic data were not significantly different between the two groups as regard patients' age, gender, body mass index, Charlson Comorbidity Index, reasons for replacement, and length of follow-up. Surgical time was greater in the VVC group (95.7 ± 22.5 min vs 88.6 ± 17.1 min, respectively, p = 0.032). Postoperative KSS, range of motion and radiographic data did not differ significantly between the two groups. Overall revision rate and revision rate for mechanical failure after 5 years of follow-up was not statistically different between the two groups. Considering only the revision rate due to periprosthetic infection, the risk was higher in patients with primary VVC implants (p = 0.013). The surgical time was the only factor that significantly affected the risk of revision for periprosthetic infection (OR 1.0636, CI 95% 1.0209–1.1081, p = 0.0032), whereas patients' gender, age and reason for TKA had no influence. Conclusions: Patients and surgeons should be aware of the higher risk of periprosthetic knee infection using a VVC prosthesis. However, the present study supports the use of VVC implants in cases of difficult knee replacements, since comparable clinical outcomes and overall revision rate was found after at least 5 years of follow up. Level of evidence: Retrospective cohort study, Level III. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the present study was to assess the kinematical behavior of a multi-radius posterior-stabilized (PS) mobile-bearing (MB) total knee arthroplasty (TKA) during an activity of daily living (Sit-To-Stand—STS) and a high demanding motor task (Deep-Knee-Lunge—DKL) using model-based dynamic RSA. We hypothesized the achievement of medial pivoting movement in both motor tasks due to the congruent geometry of the inlay with the femoral component, which should allow good stability of the medial compartment, and to the high magnitude of rotations guaranteed by the MB on the tibial side. Methods: Twenty-two randomly selected patients were recruited and prospectively evaluated. The PS MB cemented TKA was implanted with the standard technique (medial parapatellar approach, adjusted mechanical alignment). At minimum 9-month follow-up, patients were examined with model based Dynamic RSA developed in our Institute (BI-STAND DRX 2) during the execution of two motor tasks: STS and DKL. The motion parameters were evaluated using the Grood and Suntay decomposition and the low-point kinematics methods. Results: In the extension phase of DKL femur performed a greater antero posterior translation of 3.8 mm compared to STS between 0° and 20° of knee flexion (p < 0.05). Low-point analysis showed a medial pivoting movement in both motor tasks: in 62% of patients during STS and 48% during DKL. Varus-valgus rotations were lower than 1° during all the range-of-motion in both motor tasks without differences. Conclusions: Medial pivot was partially produced by this multi-radius PS MB TKA with some differences during activity of daily living (STS) and high demanding motor task (DKL). Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to report current rehabilitation recommendations after ACL reconstruction in ESSKA community, with a particular focus on the specific criteria utilized to guide activity progression Methods: A web-based survey was developed to investigate preferences between time-based and functional ACL reconstruction rehabilitation progression milestones of ESSKA community. Results: Eight hundred and twenty completed questionnaires were received. Responders were from 86 different countries worldwide, 63% of them from European countries. Functional criteria were considered more appropriate to decide if a patient can start specific activities/exercises by 67% of the responders. Good core and lower extremity neuromuscular control were the most often used functional criteria for decision-making regarding readiness for sport-specific rehabilitation (66%), sport-specific drills without (65%) and with contact (66%). Strength assessed with an isokinetic dynamometer was considered by about half of the responders a determinant to initiate sport-specific drills without (51%—isokinetic strength, LSI > 80%) and with contact (58%—isokinetic strength, LSI > 85–90%). To determine readiness for sport-specific drills, hop tests were used by 40% of respondents for drills without contact and 48% of respondents for drills with contact. Conclusion: The results of this survey involving mainly orthopaedic surgeons indicate that functional measures are considered more appropriate than milestones based on time from surgery to guide progression through the postoperative rehabilitation process after ACLR. The main clinical relevance of this study is that updated information on collective agreement could be useful for clinicians and physiotherapists to delineate their postoperative treatments after ACLR. These results should be interpreted with caution, as this sample represents only a small portion of ESSKA community involved in knee surgery and treating patients following ACLR. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: Chronic anterior ankle pain is a recognized and straightforward characteristic of anterior impingement syndrome. This retrospective study aims to evaluate outcomes, clinical and radiological results in patients affected by anterior ankle impingement, in a context of early osteoarthritis, and treated with mini-open anterior ankle arthrolysis, in the perspective to delay or avoid other demolitive surgical options, such as total ankle replacement and joint fusion. Methods: In total, 49 patients (50 feet, mean age 45 years) undergone mini-open anterior ankle arthrolysis for anterior impingement, fulfilled inclusion criteria and gave their consent and have been enlisted in the study. Patients were retrospectively reviewed with AOFAS ankle-hindfoot score and SF-36 score at a minimum follow-up of 36 months. Statistical analysis was performed. Results: A marked improvement was noticed in terms of preoperative clinical score (mean AOFAS score 47.32 ± 17.89) compared to follow-up clinical score (mean AOFAS score 70.66 ± 16.62; p < 0.005), and all of 8 SF-36 domains showed statistically improved (p < 0.05) from preoperative to follow-up. Statistical significance has been shown. Conclusions: It is possible to consider the mini-open anterior arthrolysis, thanks to the reduction of the painful symptomatology, a valid tool for procrastinating more invasive interventions such as arthrodesis or prosthetic replacement in patients with grade 1 or 2 of ankle osteoarthritis. [ABSTRACT FROM AUTHOR]

Background: Matrix-assisted autologous chondrocyte transplantation (MACT) procedures have been developed to overcome some of the limits of first-generation autologous chondrocyte implantation. However, while good autologous chondrocyte implantation results have been documented over time, data are scarce on the long-term MACT results. Purpose: To evaluate long-term clinical results of a large cohort of patients treated with hyaluronic acid–based MACT for articular cartilage defects of the knee. Study Design: Case series; Level of evidence, 4. Methods: A long-term evaluation of 113 patients was performed (91 men, 22 women; mean ± SD age, 29.0 ± 10.6 years) for 115 knees affected by chondral and osteochondral lesions of the femoral condyles and trochlea. Of these, 61 knees had undergone previous surgery, while other procedures were combined during the same operation in 48 knees. These patients were prospectively evaluated before surgery and at 2, 5, and 10 years after surgery, as well as at a final mean follow-up of 15 years (range, 12-18 years), with various clinical scores: International Knee Documentation Committee (IKDC), EuroQol visual analog scale (EQ-VAS), and Tegner. Both surgical and clinical failures were documented. Results: The IKDC subjective score increased from the basal level of 39.9 ± 14.6 (mean ± SD) to 77.3 ± 20.5 (P <.0005) at 2 years; results remained stable up to the 15-year follow-up (76.9 ± 20.5). EQ-VAS and Tegner scores showed a statistically significant improvement up to 10 years, with a further significant improvement at the final follow-up. A failure rate of 15.0% was documented, which increased to 21.7% when clinical failures were also considered. A worse outcome was found for older age (P <.0005), female sex (P =.002), degenerative lesions (P <.0005), longer duration of symptoms (P =.005), and previous surgery (P <.0005). Conclusion: Arthroscopic MACT offered good and long-lasting results that were stable over time and resulted in a limited number of failures and reinterventions for up to 15 years of follow-up. Several factors were identified as having a prognostic value: a worse outcome could be expected in older patients, female patients, those affected by lesions with a degenerative cause, those having a longer duration of symptoms, and patients who underwent previous surgery. [ABSTRACT FROM AUTHOR]

Purpose: Which total knee arthroplasty (TKA) design represents the better solution to restore a correct knee biomechanics is still debated. The aim of this study was to compare posterior stabilized (PS) and cruciate retaining (CR) version of the same TKA design (femoral component with an anatomic sagittal radius-J-curve design) by the use of dynamic Roentgen stereophotogrammetric analysis (RSA). The hypothesis was that the two models influence differently in vivo knee kinematic.Methods: A cohort of 16 randomly selected patients was evaluated 9 months after surgery: Zimmer PERSONA® was implanted, eight with CR design and eight with PS design. The kinematic evaluations were performed using a Dynamic RSA (BI-STAND DRX 2) developed in our Institute, during the execution of the sit-to-stand motor task. The motion parameters were obtained using the Grood and Suntay decomposition and the low-point kinematics methods.Results: PS TKA lateral femoral compartment had a wider anterior translation (17 ± 2 mm) than the medial one (11 ± 2 mm), while the two compartments of CR TKA showed a similar anterior translation (medial: 9 ± 2 mm/lateral: 11 ± 2 mm). T test for comparison between CR and PS TKA of antero-posterior translation showed a statistically significant difference (p < 0.05) in the flexion range between 15° and 40°. The CR prosthesis did not anteriorly translate during flexion. The PS design translated anteriorly showing a roll-forward mechanism during extension from 80° to 18° of flexion and a posterior translation from 18° to 0°. The same significant differences (p < 0.05) between the PS and CR groups were found comparing the low-point positions of the femoral condyles in the range of flexion between 25° and 40° for the medial compartment and between 15° and 25° for the lateral compartment.Conclusions: Dynamic RSA was able to investigate for the first time in vivo the kinematic behaviour of PS and CR version of the same TKA J-curve design. PS type showed a medial pivot during sit-to-stand motion task, while the CR type showed a cylindrical movement. Further studies are needed to evaluate the impact of different TKA designs on clinical results.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Background: Brachymetatarsia is a rare abnormality of the foot which occurs most frequently in the first and fourth metatarsals. The aim of this study was to evaluate the efficacy of gradual metatarsal lengthening by external fixator for treatment of brachymetatarsia of the fourth ray. The hypothesis was that with external fixation it would be possible to achieve the desired length of the metatarsal with a low rate of complications. Secondarily, in cases requiring a greater amount of correction, it was hypothesized that an opportune rate of bone consolidation would be achievable using a traditional oscillating saw without predrilling or use of a cold osteotome.Methods: Between 2013 and 2016, 12 eligible patients and 13 feet underwent gradual metatarsal lengthening by an external fixator (MiniRail System M103, Orthofix) due to brachymetatarsia of the fourth ray. Mean age at surgery was 24.5±5.3 years (range 19-36), with mean follow-up of 22.3±8.3 months. Clinical evaluation was performed with the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score. Radiographic assessment was performed on follow-up using non-weightbearing dorsoplantar foot radiographs.Results: The mean AOFAS lesser MTP-IP score improved from a preoperative score of 76.6±7.1 points (range 62-85 points) to a postoperative score of 90.3±3.0 points (range 86-95 points). The average amount of lengthening was 16.8±3.9mm (range 8-22mm). Mean shortening, final lengthening, Healing Index, period of treatment, and complications are also reported. The operative technique is described.Conclusions: Gradual metatarsal lengthening with external fixator is an effective treatment for brachymetatarsia and can restore forefoot anatomy with good clinical outcomes, a low rate of morbidity and complications in selected cases. Particular attention should be given when treating patients with shortening >20mm. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the present study was to translate, cross-culturally adapt, and assess the psychometric properties of the Pedi-IKDC and Pedi-FABS scores in the Italian paediatric population with various knee pathologies. Methods: In accordance with the Paediatric Anterior Cruciate Ligament Monitoring Initiative (PAMI) research protocol, the original English versions of the questionnaires were translated into Italian. All patients aged 8–16 and scheduled for knee surgery were considered eligible in the study. An open-source platform was implemented to collect responses to the surveys which included general patient information, the questionnaires Pedi-IKDC, and Pedi-FABS. Two surveys were sent under stable clinical conditions before surgery (Q1 and Q2); a third survey was sent 3–4 months after surgery (Q3). The following properties were calculated: reliability, internal consistency, criterion validity, responsiveness, and floor/ceiling effects. Results: Eighty-nine patients completed Q1, 81 patients completed Q2, and 49 patients completed Q3. Both questionnaires demonstrated acceptable properties. Pedi-IKDC: standard error of measurement (SEM) = 4.4, smallest detectable change (SDC) = 12.3, interclass correlation coefficient (ICC) = 0.96, Cronbach alpha (α) = 0.92, moderate-to-low correlation to Pedi-FABS, effect size (ES) = 0.79, standardized response mean (SRM) = 0.86, floor = 0%, ceiling = 22%. Pedi-FABS: SEM = 2.1, SDC = 5.8, ICC = 0.94, Cronback alpha (α) = 0.93, moderate-to-low correlation to Pedi-IKDK, ES = 0.60, SRM = 0.51, floor = 19%, ceiling = 0%. Conclusions: The Italian version of Pedi-IKDC and Pedi-FABS is valuable tools for patient assessment, by demonstrating good psychometric properties. In clinical setting, these questionnaires can be used to properly evaluate outcomes in Italian pediatric patients with knee pathologies. Level of evidence: II. [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]

Background: Meniscal allograft transplant (MAT) is considered an effective procedure for reducing pain and improving knee function. Nevertheless, the current knowledge regarding the results of MAT is limited to short- to mid-term follow-up studies, especially for arthroscopic techniques. Purpose: To evaluate the long-term clinical outcomes, reoperations, and failures with a minimum follow-up of 10 years after fresh-frozen MAT performed arthroscopically with soft tissue fixation. Study Design: Case series; Level of evidence, 4. Methods: A total of 46 patients (age, 36.6 ± 10.6 years; 36 male, 10 female) who underwent medial MAT (n = 27) or lateral MAT (n = 19) with a minimum 10-year follow-up were evaluated with the Lysholm score, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale for pain, and Tegner score. Surgical failure was defined as the need for partial or total graft removal (meniscectomy or knee replacement), and clinical failure was defined as the need for partial or total graft removal in addition to a poor Lysholm score (<65 points) at final follow-up. Survival analysis was performed with Kaplan-Meier curve, and clinical scores were analyzed based on the Patient Acceptable Symptom State (PASS) for MAT. Results: 10-year survival and clinical data were available for 38 patients. Because 6 meniscectomies were required, the rate of survival free from surgical failure was 91% at 5 years and 86% at 10 years. Lower survival was reported in lateral MAT (73%) compared with medial MAT (96%). Because a further 4 patients had poor Lysholm scores, the rate of survival free from surgical and clinical failure was 87% at 5 years and 70% at 10 years. The average Lysholm score at final follow-up was 82 ± 20, and 60% to 82% of patients achieved PASS of the various KOOS subscales. The Tegner score and the KOOS Sport score significantly decreased from mid-term to long-term evaluation (P <.001 and P <.05, respectively). Other KOOS subscales and the Lysholm score remained stable at long-term evaluation. No significant differences were found between isolated MAT or combined MAT regarding subjective scores, surgical failures, or clinical failures. Conclusion: Up to 10 years after surgery, 86% of fresh-frozen MATs with soft tissue fixation were still in situ, and satisfactory clinical results were present for about 70% of patients. Decline of clinical outcomes from midterm to long term was noted only in sports-related scores. A higher number of overall reoperations was noted in female patients, whereas a higher risk of failure was present in the patients with lateral MAT. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic debridement with graft preservation has been advocated as the treatment of choice for septic arthritis after anterior cruciate ligament (ACL) reconstruction, but no previous studies have investigated if hardware removal, while retaining the graft in situ, improves the success rate. Moreover, it is unclear whether the premature removal of fixation devices may affect graft integration and knee stability. Purpose/Hypothesis: The purpose was to assess the clinical and functional outcomes of patients with septic arthritis after ACL reconstruction who underwent arthroscopic debridement, while retaining the graft in situ but removing fixation devices, and to determine if premature hardware removal affects graft integrity and function. The hypothesis was that arthroscopic debridement with hardware removal would be effective in eradicating infections while not compromising graft integration and function. Study Design: Case series; Level of evidence, 4. Methods: From a cohort of 2384 cases of arthroscopic ACL reconstruction, 24 patients with postoperative septic arthritis were included for the analysis; 18 patients were available for a clinical evaluation using the International Knee Documentation Committee (IKDC) form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, and Tegner score at a minimum 12-month follow-up. Knee laxity was assessed clinically with standardized manual laxity tests and instrumentally using an arthrometer and a triaxial accelerometer. Additionally, 3-T magnetic resonance imaging (MRI) at final follow-up was performed, focusing on the graft signal, the cartilage status, and the occurrence of arthrofibrosis. Results: Eradication of the infection was achieved in all cases, and only 1 graft removal was performed because of insufficient tension. Among the remaining 23 patients, a single arthroscopic debridement procedure with hardware removal while preserving the graft was effective in 21 cases (91%) at a mean of 30 ± 37 days from ACL reconstruction to debridement. At last follow-up, 2 patients required a further ACL revision procedure. The mean IKDC, WOMAC, Lysholm, and Tegner scores of the patients available for the clinical evaluation were 75 ± 19, 90 ± 8, 79 ± 21, and 6 ± 2, respectively. No abnormal laxity was reported on manual testing, and arthrometric and accelerometer tests also demonstrated good knee stability (mean KT-1000 arthrometer side-to-side difference was 1.6 ± 1.2 mm at manual maximum force). On MRI, a good graft signal was found in 50% of cases, while concomitant signs of arthrofibrosis were detected in 81% of patients. Severe cartilage defects (International Cartilage Repair Society grade ≥3) were reported in 63% of cases. Conclusion: Arthroscopic debridement with hardware removal was effective in the eradication of infections after ACL reconstruction with extra-articular fixation while preserving graft integrity without compromising knee stability. Patients and surgeons should be aware of complications that might affect the outcome, particularly arthrofibrosis and chondrolysis. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study is to determine the efficacy of tibiotalocalcaneal arthrodesis by reamed intramedullary nail in the management of the distal tibia non-unions, associated with end-stage osteoarthritis of ankle and subtalar joints.Materials and Methods: 8 patients with radiographical and clinical diagnosis of non-union of the distal tibia have been treated with tibiotalocalcaneal arthrodesis by intramedullary retrograde nail and were retrospectively evaluated. Patients were radiographically and clinically evaluated preoperatively and at final follow-up regarding: satisfaction, AOFAS, VAS. Surgical technique is described.Results: Mean follow-up was 69.2 ± 23.2 months (range 48-108). In terms of subjective outcome, patients reported a highly satisfying result. All patients returned to daily activities, with an average time of 24.7 ± 8.7 weeks. 6 patients could return to their previous work activity, with an average time of 23.6 ± 6.3 weeks.Conclusions: The procedure showed good results at final follow up. Consolidation was achieved in all the treated cases. Considering AOFAS and VAS scores at final follow-up, there was an evident improvement of the conditions of the patients. [ABSTRACT FROM AUTHOR]

Background: A biodegradable polyurethane scaffold was developed to treat patients with the challenging clinical condition of painful partial meniscal defects. Hypothesis: The use of an acellular polyurethane scaffold in patients with symptomatic partial meniscal defects would result in both midterm pain relief and improved function. Study Design: Case series; Level of evidence, 4. Methods: A total of 155 patients with symptomatic partial meniscal defects (101 medial and 54 lateral) were implanted with a polyurethane scaffold in a prospective, single-arm, multicentric study with a minimum 5-year follow-up. Clinical outcomes were measured with the visual analog scale for pain, International Knee Documentation Committee subjective knee evaluation form, Lysholm knee scale, and Knee injury and Osteoarthritis Outcome Score at baseline and at 2- and 5-year follow-ups. Magnetic resonance imaging (MRI) was used to evaluate the knee joint, meniscal implant, and meniscal extrusion. Kaplan-Meier survival analysis was also performed. Removal of the scaffold, conversion to a meniscal transplant, and unicompartmental/total knee arthroplasty were used as endpoints. Results: Eighteen patients were lost to follow-up (11.6%). The patients who were included in this study showed significant clinical improvement after surgery as indicated by the different outcome measures (P =.01). However, the clinical improvement tended to stabilize between 2 and 5 years of follow-up. MRI scans of the scaffolds in 56 patients showed a smaller-sized implant in the majority of the cases when compared with the native meniscus with an irregular surface at the 5-year follow-up. During the follow-up period, 87.6% of the implants survived in this study. At 5 years of follow-up, 87.9% of the medial scaffolds were still functioning versus 86.9% of the lateral scaffolds. In total, 23 treatments had failed: 10 removed scaffolds because of breakage, 7 conversions to meniscal allograft transplantation, 4 conversions to unicompartmental knee arthroplasty, and 2 conversions to total knee arthroplasty. Conclusion: The polyurethane meniscal implant was able to improve knee joint function and reduce pain in patients with segmental meniscal deficiency over 5 years after implantation. The MRI appearance of this scaffold was different from the original meniscal tissue at the midterm follow-up. The treatment survival rates of 87.9% of the medial scaffolds and 86.9% of the lateral scaffolds in the present study compared favorably with those published concerning meniscal allograft transplantation after total meniscectomy. [ABSTRACT FROM AUTHOR]

Background: Several devices for obtaining dynamic fixation of the syndesmosis have been introduced in recent years, but their efficacy has been tested in only a few randomized controlled trials (RCTs), without demonstrating any clear benefit over the traditional static fixation with screws. Purpose: To perform a level 1 meta-analysis of RCTs to investigate the complications, subjective outcomes, and functional results after dynamic or static fixation of acute syndesmotic injuries. Study Design: Meta-analysis of RCTs. Methods: A systematic literature search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, and Embase electronic databases, as well as ClinicalTrials.gov for unpublished studies. Eligible studies were RCTs comparing dynamic fixation and static fixation of acute syndesmosis injuries. A meta-analysis was performed, while bias and quality of evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation guidelines. Results: Dynamic fixation had a significantly reduced relative risk (RR = 0.55, P =.003) of complications—in particular, the presence of inadequate reduction at the final follow-up (RR = 0.36, P =.0008) and the clinical diagnosis of recurrent diastasis or instability (RR = 0.10, P =.03). The effect was more evident when compared with permanent screws (RR = 0.10, P =.0001). The reoperation rate was similar between the groups (RR = 0.64, P =.07); however, the overall risk was reduced after dynamic fixation as compared with static fixation with permanent screws (RR = 0.24, P =.007). The American Orthopaedic Foot & Ankle Society score was significantly higher among patients treated with dynamic fixation—6.06 points higher (P =.005) at 3 months, 5.21 points (P =.03) at 12 months, and 8.60 points (P <.00001) at 24 months—while the Olerud-Molander score was similar. The visual analog scale for pain score was reduced at 6 months (–0.73 points, P =.003) and 12 months (–0.52 points, P =.005), and ankle range of motion increased by 4.36° (P =.03) with dynamic fixation. The overall quality of evidence ranged from "moderate" to "very low," owing to a substantial risk of bias, heterogeneity, indirectness of outcome reporting, and evaluation of a limited number of patients. Conclusion: The dynamic fixation of syndesmotic injuries was able to reduce the number of complications and improve clinical outcomes as compared with static screw fixation—especially malreduction and clinical instability or diastasis—at a follow-up of 2 years. A lower risk of reoperation was found with dynamic fixation as compared with static fixation with permanent screws. However, the lack of patients or personnel blinding, treatment heterogeneity, small samples, and short follow-up limit the overall quality of this evidence. [ABSTRACT FROM AUTHOR]