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Osteoarthritis (OA) is the most common degenerative joint disease and the leading cause of disability in the adult population worldwide. The knee is the most prevalent site of symptomatic arthritis. Treatment options for OA include drugs, surgery and, more recently, biological treatments. Injectable ortho-biological treatments include autologous and more rarely heterologous preparations employed inside and outside the operating room to assist bone and soft tissue regeneration. Our aim was to analyze the rationale for use of injectable ortho-biological treatments such as platelet-rich plasma (PRP) and mesenchymal cells from bone marrow, adipose tissue, and placenta/umbilical cord, in patients with severe OA of the knee (Kellgren-Lawrence grade 4).A search in PubMed, ScienceDirect and Google Scholar databases was performed using the following keywords: 'knee osteoarthritis' and 'biological treatment' or 'PRP' or 'adipose' or 'mesenchymal' or 'staminal' or 'stem cells'. Manual research throughout the reference lists of all retrieved articles was further conducted.A total of 16 articles was selected for this systematic review. The rationale for use of each ortho-biological treatment was discussed. The clinical application showed different therapeutic protocols, different follow-up periods, different outcomes analyzed and small sample size.Our study did not demonstrate uniform beneficial effects for the use of injectable ortho-biological. This prevents any advice for routine application in the treatment of severe knee OA (K-L IV). Further prospective clinical trials with randomization, larger sample size, and preliminary power calculation are needed to justify the use of injectable biologic agents in grade IV knee OA in everyday practice.

The number of joint replacements is expected to dramatically increase, and the optimization of the available resources is fundamental to maintain high clinical standards while providing an efficient treatment to an increasing number of patients. The present study describes the outcomes of the application of a rapid recovery (RR) protocol in a referral center for hip and knee replacement surgery.The medical records of every patient undergoing primary hip or knee replacement in 2019 were identified and all the relevant data were retrospectively extracted and compared to those of year 2016 (the last year before the onset of the rapid recovery protocol). The following outcomes were considered: 1) length of stay (LOS); 2) total number of TKR and THR; 3) pre- and post-operative subjective questionnaires; 4) NRS for pain at day 1 following surgery; 5) mean hemoglobin value at discharge; 6) number of blood transfusion performed; 7) complications following surgery.The mean LOS was significantly lower for patients managed through the rapid recovery protocol: 5.1 ± 1.4 days vs. 10.4 ± 2.3 days (p0.0001). The earlier discharge of patients promoted an overall increase in the total number of joint replacement procedures performed (2,806 in year 2019 vs. 2,236 in year 2016; p0.0001). Higher hemoglobin values at discharge were found in the RR group (10.6 ± 1.4 g/dl vs. 9.6 ± 1.2 g/dl, p = 0.049). No difference was observed in terms of clinical scores and overall complication rate.The application of a multimodal RR protocol for THR and TKR patients was able to reduce the length of stay and optimize the use of blood products, without increasing the risk of complications or jeopardizing the functional recovery.

Lateral ankle sprains are very common injuries that can be treated with different strategies. The aim of the present systematic review was to provide a comprehensive analysis on the treatment of acute lateral ankle sprains to clarify the possible differences in outcome between surgical and conservative management, different external supports, and different rehabilitation protocols.A literature search on three different topics was carried out on PubMed, Scopus, and Web of Science databases on June 25th, 2021. The main objective of the literature search was to identify the randomized trials comparing: (1) surgery to conservative management, (2) different external supports, and (3) different rehabilitation protocols for the treatment of acute lateral ankle sprains. Two investigators extracted independently relevant data from each paper and assessed the quality of the trials using the Cochrane Risk of Bias Assessment.A total of 12 studies for the first topic, 8 for the second one and 4 for the last one were included in this review. 8 out of 12 RCTs demonstrated a superior outcome and better socio-economic impact of conservative treatment compared to surgical management. In the other two comparisons, due to the wide variety of braces used and the different rehabilitation protocols, inconclusive results were obtained.Conservative treatment should be the first choice for severe acute lateral ankle sprains, as it provides satisfactory functional outcomes without the risks and costs of surgery. It was not possible to identify the best external support, but a preference toward flexible braces emerged since they allow an earlier return to daily activities. The paucity of studies comparing different rehabilitation protocols precluded the possibility of defining the ideal one.

Objective: Sensory deficits are important risk factors for delirium but have been investigated in single-center studies and single clinical settings. This multicenter study aims to evaluate the association between hearing and visual impairment or bi-sensory impairment (visual and hearing impairment) and delirium. Design: Cross-sectional study nested in the 2017 "Delirium Day" project. Setting and participants: Patients 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes, and hospices in Italy. Methods: Delirium was assessed with the 4AT (a short tool for delirium assessment) and sensory deficits with a clinical evaluation. We assessed the association between delirium, hearing and visual impairment in multivariable logistic regression models, adjusting for: Model 1, we included predisposing factors for delirium (ie, dementia, weight loss and autonomy in the activities of daily living); Model 2, we added to Model 1 variables, which could be considered precipitating factors for delirium (ie, psychoactive drugs and urinary catheters). Results: A total of 3038 patients were included; delirium prevalence was 25%. Patients with delirium had a higher prevalence of hearing impairment (30.5% vs 18%; P < .001), visual impairment (24.2% vs 15.7%; P < .01) and bi-sensory impairment (16.2% vs 7.5%) compared with those without delirium. In the multivariable logistic regression analysis, the presence of bi-sensory impairment was associated with delirium in Model 1 [odds ratio (OR) 1.5, confidence interval (CI) 1.2-2.1; P = .00] and in Model 2 (OR 1.4; CI 1.1-1.9; P = .02), whereas the presence of visual and hearing impairment alone was not associated with delirium either in Model 1 (OR 0.8; CI 0.6-1.2, P = .36; OR 1.1; CI 0.8-1.4; P = .42) or in Model 2 (OR 0.8, CI 0.6-1.2, P = .27; OR 1.1, CI 0.8-1.4, P = .63). Conclusions and implications: Our findings support the importance of routine screening and specific interventions by a multidisciplinary team to implement optimal management of sensory impairments and hence prevention and the management of the patients with delirium.

The aim of the study was to review the available literature on the application of oxygen-ozone therapy (OOT) in the treatment of low back pain (LBP), to understand its therapeutic potential and compare it with other available treatment options.A systematic review was performed on the PubMed and Scopus databases, with the following inclusion criteria: (1) randomized controlled trials (RCTs), (2) published in the last 20 years, (3) dealing with OOT in patients with LBP and herniated disc, (4) comparing the results of OOT with those of other treatments. The risk of bias was assessed by the Cochrane Risk of Bias tool.Fifteen studies involving 2597 patients in total were included. Patients in the control groups received different treatments, from oral drugs to other injections, instrumental therapy and even surgery: corticosteroids were used in 5 studies, analgesic therapy in 2 studies; placebo, microdiscectomy, laser-therapy, TENS and postural rehabilitation, percutaneous radiofrequency intradiscal thermocoagulation and psoas compartmental block were tested in the other trials. Looking at the quality of the literature, none of the studies included reached "good quality" standard, 3 were ranked as "fair" and the rest were considered "poor". Comparison of OOT results with other approaches showed that, in the majority of studies, OOT was superior to the control treatment, and also when compared to microdiscectomy, ozone showed non inferiority in terms of clinical outcomes.The analysis of literature revealed overall poor methodologic quality, with most studies flawed by relevant bias. However, OOT has proven to be a safe treatment with beneficial effects in pain control and functional recovery at short to medium term follow-up.

To analyze the available evidence comparing the clinical and functional outcomes of physiotherapy vs. surgical repair in the management of degenerative rotator cuff tears (RCTs), and to perform a meta-analysis to clarify the possible superiority of one approach vs. the other.A literature search was carried out on the PubMed, Scopus and Web of Science databases on May 30th, 2020, to identify all the randomized trials comparing surgery to conservative management of degenerative rotator cuff tears. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, overall clinical findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment.A total of 7 studies, including 326 patients and dealing with conservative treatment vs. surgical repair for rotator cuff tears, were included in this study. Although surgery provided superior results both in terms of VAS (p=0.017) and Constant score (p0.0001) compared to conservative management at 1 year follow-up, this superiority did not reach the "minimal clinical important difference". Otherwise, a few data are available about long-term outcomes, thus there is insufficient evidence about the role of surgery to prevent the progression of tendon wear.A proper rehabilitation program is able to provide similar results compared to surgery at a short term follow-up in degenerative RCTs. Further long term data are necessary to understand if tendon repair might have a protective role towards worsening of degeneration thus providing better clinical outcome than conservative management.

Bucket-handle tears represent approximately 10% of all meniscal tears. Despite the common treatment is subtotal meniscectomy, repair is technically feasible although complex, and represents a key strategy to avoid severe meniscal tissue loss that could accelerate joint degeneration over time. The aim of this retrospective study was to determine the outcomes of arthroscopically-assisted bucket-handle tear repair, and to identify factors correlating with clinical results. Fifty-four patients affected by meniscal bucket handle tear were included in the present retrospective analysis and evaluated up to mean 4-years follow-up. All patients were treated by arthroscopic-assisted all-inside repair. The primary outcome was considered the need for a re-operation due to failure of meniscal repair. Patients were also evaluated by the following items: KOOS, Lysholm, Tegner, IKDC-subjective and Quadruple-VAS score. Subgroup analysis was performed to identify whether concurrent ACL reconstruction, side of the lesion, age at surgery and time from injury to repair could influence clinical outcome. Ten out 54 patients (18.5%) were considered failed and needed reoperation, mainly within one year from surgery. Overall, there was a significant increase in all clinical scores considered and patients were able to get back to previous sport activity level. Patients with concurrent ACL reconstruction presented a lower risk of failure (p=0.025). Patients with lateral meniscus repair showed better clinical outcome compared to medial meniscus. Timing from injury and age at surgery did not correlated with clinical outcome. Our series showed fair results in bucket handle repair up to middle term evaluation. Concomitant ACL reconstruction was associated with lower failure rate whereas lateral meniscus involvement was associated with higher functional scores at final follow-up evaluation.

Analyzing the available evidence by comparing the role of arthroscopic surgery and conservative treatment in the management of degenerative meniscopathy.A literature search was carried out on the PubMed, EMBASE, Scopus, and PEDro databases in May 2019 to identify all the randomized controlled trials (RCTs) comparing arthroscopic surgery to conservative management of painful but stable degenerated menisci. The quality of the RCTs was assessed using the Cochrane Risk of Bias Assessment.A total of 10 studies, including 1525 patients and dealing with conservative treatment vs. arthroscopic surgery were included in this review. In eight studies the effectiveness of exercise therapy was compared to surgery; in one study the effectiveness of intra-articular steroid injection was compared to surgery; in one study the effectiveness of placebo surgery was compared to partial meniscectomy. In all studies, no significant inter-group difference in terms of knee pain and knee function were observed at any follow-up evaluation.Degenerative meniscal tears, without symptoms of locking and catching, can be successfully managed by a proper regimen of physical therapy as a first line treatment. Surgical approach might be considered in case of poor response after conservative treatment.

Background: Return to sport after revision ACL reconstruction is a controversial topic, several studies reported the results of different techniques and graft in sportsman, presenting an incredibly wide range of return to the same pre-injury activity level, from 0% to 100%. The purpose of this study was to evaluate the clinical outcomes and return to sport rate in young athletes after non anatomic double-bundle revision ACL reconstruction with Achilles allograft. Hypothesis: The present revision technique was effective in terms of stability, return to sport and functional outcomes. Material and methods: All the athletes undergone Revision ACL reconstruction with non-irradiated Achilles tendon allograft with a non-anatomical double-bundle technique were included in the study. A split Achilles tendon allograft was used to reproduce the anteromedial (AM) bundle using the over-the-top position, while the posterolateral (PL) bundle was reconstructed through a femoral tunnel located in the anatomical PL footprint. Sport activity, knee function with Lysholm score, knee laxity and re-injury or re-operations were evaluated. Results: Twenty-six athletes (23 males, three females) with a mean age of 23.4. ±. 3.6 years were evaluated at a mean follow-up of 6.0. ±. 1.6 years. Overall 69% of patients returned to sport both at elite (44%) or county level (56%) after a mean 6.7. ±. 1.5 (3-9 range) months. The mean Lysholm score showed a significant improvement from 64.4. ±. 8.1 at pre-operative status to 83.8. ±. 11.3 at final follow-up (P 5. mm side-to-side difference at KT-1000. Therefore, the overall survival rate at mean six years follow-up was 81%. Conclusion: The ACL revision with a double-bundle technique using Achilles tendon allograft was successful in 81% of athletes at six years mean follow-up. Type of study and level of evidence: Retrospective case series, level IV.

Mycoplasma mycoides subsp. mycoides is the etiological agent of contagious bovine pleuropneumonia (CBPP). While several findings on CBPP prevalence in Nigeria were documented, no data were reported about the genomic characterization of Nigerian M. mycoides subsp. mycoides strains. Here, we present the draft genome sequences of two novel M. mycoides subsp. mycoides strains isolated in Nigeria.

Purpose: The aim of this study was to document, at mid-term follow-up, the clinical and MRI outcome of a polyurethane-based cell-free scaffold implanted to treat painful partial meniscus loss. Methods: Eighteen consecutive patients were enrolled and treated with arthroscopic polyurethane meniscal scaffold implantation and, in case of other comorbidities, with concurrent surgical procedures: 16 patients (9 men and 7 women, mean age 45 ± 13 years, mean BMI 25 ± 3, 12 medial and 4 lateral implants) were prospectively evaluated with the subjective and objective IKDC and the Tegner scores at 24, 36, 48, 60, and 72 months of follow-up. Eleven patients were also evaluated by 1.5-T MRI at the final follow-up. Results: The IKDC subjective score showed a significant improvement from baseline to 24 months (45.6 ± 17.5 and 75.3 ± 14.8, respectively; p = 0.02) and subsequent stable results over time for up to 72 months (final score 75.0 ± 16.8). The Tegner score improvement between pre-operative status and final follow-up was also significant (p = 0.039). Nevertheless, the final score remained significantly lower than the pre-injury sports activity level (p = 0.027). High-resolution MRIs documented the presence of abnormal findings in terms of morphology, signal intensity, and interface between the implant and the native meniscus. Implant extrusion and bone oedema at the treated compartment were also observed in most of the cases, even though no correlation was found between imaging findings and clinical outcome. Conclusions: The present study reports satisfactory clinical outcomes at mid-term follow-up after polyurethane-based meniscal cell-free scaffold implantation. The treatment was effective both in cases of isolated partial meniscal lesions and in complex cases requiring the combination with other surgical procedures. On the other hand, a high rate of altered MRI aspects was documented. However, no correlation was found between the altered imaging parameters and the overall positive clinical findings, thus supporting the use of this procedure to treat painful partial meniscus loss. Level of evidence: Case series, Level IV.

Several eminent surgeons made breakthroughs in knee surgery throughout the nineteenth and twentieth centuries. Before that, knee injuries were only treated conservatively and it was thanks to the progress made in the field of biomechanics and biology that new surgical treatments were proposed. The history of medicine recalls some illustrious surgeons such as Thomas Annandale and Mayo Robson who were the first to perform and describe their revolutionary experience regarding meniscal and anterior cruciate ligament surgery. Less famous are the forefathers of multi-ligament reconstructive surgery: the purpose of this paper was to shed some light on the pioneers of this particular field of orthopaedic practice, which is gaining increasing interest in current clinical practice. Level of evidence V.

Magnetic scaffolds have recently attracted significant attention in tissue engineering due to the prospect of improving bone tissue formation by conveying soluble factors such as growth factors, hormones, and polypeptides directly to the site of implantation, as well as to the possibility of improving implant fixation and stability. The objective of this study was to compare bone tissue formation in a preclinical rabbit model of critical femoral defect treated either with a hydroxyapatite (HA)/magnetite (90/10 wt %) or pure HA porous scaffolds at 4 and 12 weeks after implantation. The biocompatibility and osteogenic activity of the novel magnetic constructs was assessed with analysis of the amount of newly formed bone tissue and its nanomechanical properties. The osteoconductive properties of the pure HA were confirmed. The HA/magnetite scaffold was able to induce and support bone tissue formation at both experimental time points without adverse tissue reactions. Biomechanically, similar properties were obtained from nanoindentation analysis of bone formed following implantation of magnetic and control scaffolds. The results indicate that the osteoconductive properties of an HA scaffold are maintained following inclusion of a magnetic component. These provide a basis for future studies investigating the potential benefit in tissue engineering of applying magnetic stimuli to enhance bone formation. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 546-554, 2018.

BACKGROUND: To investigate time to return to sport and rate of professional sport activity in a homogenous group of competitive soccer players 4 years after anterior cruciate ligament (ACL) reconstruction and rehabilitation. METHODS: Twenty-one male professional soccer players (mean age 22.9±5.4 years) underwent non-anatomical double-bundle autologous hamstring ACL reconstruction and followed the same rehabilitative protocol. Clinical evaluation was performed preoperatively and at 3, 6 and 12-month follow-up. Data regarding return to train and official match, sport activity, complications and revision surgeries were collected at 4-year follow-up. RESULTS: Laxity test (KT-2000) and total KOOS mean score resulted in a significant improvement from the preoperative status to the 12-month follow-up (p

Purpose To evaluate the effects of kinesiophobia on both phases immediately after surgery and the final results after total knee arthroplasty (TKA). Methods This study evaluated prospectively 101 patients (mean age 66 ± 8.0 years, 70 women and 31 men), 5 days after surgery, at 1, 6, 12 months, and at a mean final follow-up of 3.2 ± 0.7 years (2.0–4.2 years). Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK: Activity Avoidance—TSK1 and Harm—TSK2 subscales), and results were evaluated with range of motion, pain and function on 0–10 numeric rating scales, WOMAC and SF-12 (Physical and Mental subscales) scores. Results TSK1 was correlated with the acute postoperative pain measured at 5 days (p = 0.031), pain measured at 12 months (p = 0.018), patient perceived function at 12 months (p = 0.025), SF-12P at 6 months (p < 0.001), SF-12P and SF-12M at 12 months (p = 0.001 and p = 0.005, respectively), and WOMAC at both 6 and 12 months of follow-up (p = 0.005 and p = 0.001). The effect of TSK 1 on the final WOMAC score was significant when corrected by age and sex (p = 0.049, η 2 = 0.041): the youngest female patients were affected even by moderate kinesiophobia levels. Conclusions Fear of pain and even more avoidance of movement are strongly correlated both with the acute postoperative pain perception and recovery after surgery up to 1 year, thus presenting a relevant clinical impact on the outcome after TKA. Moreover, this study showed that even though at longer follow-up its impact decreases, patients with higher levels of kinesiophobia may present a poorer final outcome, especially women. Level of evidence IV.

Type I collagen films have been functionalized on their surfaces by plasma treatment with carboxyl and amino groups to improve their potential for grafting bioactive molecules. The physico-chemical properties of the plasma-treated films were evaluated and compared to the untreated materials by water contact angle, SEM and AFM. The presence of new functional groups on the film surfaces has been assessed by ATR-FTIR spectra after chemical derivatization. Moreover, the biocompatibility of the plasma-treated films was studied with MG-63 human osteoblast-like cells, evaluating cell proliferation, viability and morphology at 1, 3 and 7. days. © 2012 Elsevier Inc.

The objective of this study was to verify whether pre-reconstruction laxity condition effects post-reconstruction outcome. A total of 100 patients who underwent navigated Anterior Cruciate Ligament (ACL) reconstruction were included in the study and knee laxity analysed retrospectively. The knee was assessed in six different laxity tests before and after ACL reconstruction, namely antero-posterior (AP) and internal-external (IE) at 30° and 90°, and varus-valgus (VV) rotations at 0° and 30° of flexion. For each test, the least square (LS) fitting line based on pre-operative-to-post-operative laxity value was calculated. To what degree the post-operative laxity value is explainable by the corresponding pre-operative condition was evaluated by the LS line slope. Post-operatively, for each single patient, the grade of laxity decreased at any evaluated test. The strongest influence of pre-operative-to-post-operative laxity values was found during IE30 and IE90 tests. While AP30 and VV0 tests seem to be those in which the post-reconstruction laxity was barely affected by the pre-surgery condition. The analysis of the global laxity reduction confirms the previous results. Following this hypothesis, our study remarks on the importance of combined lesions to secondary restraints and the importance of fully understanding the residual laxity to optimize the surgical technique.

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.

This case report outlines some of the challenges as well as limitations in correction of osteoarthritis of the knee in combination with extra-articular deformities,and provides a novel and straightforward surgical solution in overcoming these challenges. We describe the case of a 37-year-old male who suffered from advanced bilateral tri-compartmental knee arthritis due to untreated bloodstream-sourced osteomyelitis after birth. Radiographs and surgery confirmed extremely severe deformities. We performed two different surgical techniques in order to correct extra-articular deformities (one-stage approach of concurrent tibial and femoral osteotomy and total knee arthroplasty on one side, and soft tissue balancing with “pie-crusting technique” plus total knee arthroplasty on the other side), with description of subsequent results at 36-months follow-up.

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 Single-Bundle with Lateral Plasty and Double-Bundle reconstruction on static and dynamic laxity in combined ACL- and ALL-deficient knees. Methods: The study included 10 fresh-frozen human knees. The joints were analyzed in the following conditions: ACL + ALL resection, Single-Bundle with Lateral Plasty (SBLP) reconstruction, Double-Bundle (DB) reconstruction. Testing parameters were: 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 5 Nm torque and acceleration and internal rotation Pivot-Shift (PS) test. Kinematics was acquired by a navigation system. Paired Student’s t test was conducted to assess statistical difference (P < 0.05). Results: At both 30° and 90° of knee flexion, both SBLP and DB surgical techniques showed a significant reduction (P < 0.01) of anterior–posterior tibial displacement compared to the resection of ACL + ALL. At 30° on knee flexion it is the SBLP that allows the greatest reduction of internal rotational laxity when compared to DB reconstruction. Concerning the PS test, only SBPL procedure had a significant laxity decrease considering the acceleration reached by the joint when compared with the ACL + ALL state (P < 0.01). Conclusion: Clinical relevance of this study is that the internal rotation and PS test were more efficiently controlled by the SBLP technique than by the DB one at both 30° and 90° of flexion in case of ACL + ALL lesions.

In the last two decades, the achievements of tissue engineering provided the surgeons with a pool of new and promising options for the treatment of cartilage defects. Cell-based regenerative techniques, also in combination with various biomaterials, were proposed to improve the tissue quality and the clinical outcomes. Despite several investigations that showed satisfactory clinical results in the long term, the need for two surgical procedures and the related costs limited their use. Thus, the possibility to avoid any cell augmentation by implanting biomaterials able to exploit the patient self-regenerative potential in situ was explored. Since then, several matrices were successfully introduced in the clinical use, and their intrinsic ability to promote tissue regeneration produced positive results in terms of clinical improvement. Also, some biomaterials were combined to reproduce the requirements of both bone and cartilage, in order to address osteochondral defects. This narrative review aims at resuming the state of the art concerning the clinical use of acellular scaffolds for the treatment of cartilage conditions.

Patient engagement in a patient–physician decision-making process has been correlated with satisfaction and clinical outcomes. Aim of this study is to evaluate if patient control preference may also influence TKA results. One hundred and seventy-six patients (120w–56m, age 66 ± 9 years, BMI 28 ± 4) underwent TKA and were prospectively evaluated, before surgery and at 6 and 12 months. The preoperative assessment included the Control Preference Scale (CPS) and other scales measuring psychological aspects (STAI, BDI, TSK), as well as SF12 (physical and mental subscales) and the assessment of pain and function. Pain, function, and SF12 subscales were then used to evaluate the improvement at 6- and 12-month follow-up. Pain, function, and SF12 scores improved at 6 and 12 months. CPS correlated with the outcome: pain and functional improvement at 6 months (p = 0.014; p = 0.003, respectively), patient function at 6 months (p = 0.022), improvement of SF12 physical subscale at 6 and 12 months (p = 0.027; p = 0.037, respectively), and satisfaction at 6 months (p = 0.033). Moreover, the multivariate analysis confirmed the importance of CPS regardless of other demographic, physical or psychological characteristics. In contrast with previous literature findings, this study shows that patients with more propensity for control presented lower improvements of pain and function than those more prone to rely on the physician making the decision. Physicians should be aware that the patient control preference may influence the treatment outcome and undertake measurements to optimize patient participation in the shared process to optimize the chances of TKA success. IV.

Previous studies did not take into consideration such large variety of surgery variables which describe the performed anterior cruciate ligament (ACL) reconstruction and the interaction among them in the definition of postoperative outcome. Seventeen patients who underwent navigated Single Bundle plus Lateral Plasty ACL reconstruction were enrolled in the study. Static laxity was evaluated as the value of anterior/posterior displacement at 30° and at 90° of flexion, internal/external rotation at 30° and 90° of knee flexion, varus/valgus test at 0° and 30° of flexion. The evaluated surgical variables were analyzed through a multivariate analysis defining the following models: AP30estimate, AP90estimate, IE30estimate, IE90estimate, VV0estimate, VV30estimate. Surgical variables has been defined as the angles between the tibial tunnel and the three planes, the lengths of the tunnel and the relationship between native footprints and tunnels. An analogous characterization was performed for the femoral side. Performance and significance of the defined models have been quantified by the correlation ratio (η(2)) and the corresponding p-value (*p

Deposition of nanostructured and low-wear zirconia (ZrO2) thin films on the metallic component of a total joint implant is envisaged to reduce wear of the soft ultra-high molecular weight polyethylene (UHMWPE) counterpart. In this work, morphological surface features, wear resistance and in vitro-biocompatibility of zirconia thin films deposited by the novel Pulsed Plasma Deposition (PPD) method have been investigated. Film thickness, roughness and wettability were found to be strongly dependent on deposition gas pressure. Interestingly, wear rate of UHMWPE disks coupled to zirconia-coated titanium spheres was only poorly correlated to the contact angle values, while film roughness and thickness seemed not to affect it. Furthermore, wear of UHMWPE, when coupled with zirconia coated-titanium spheres, significantly decreased with respect to uncoated spheres under dry or NaCl-lubricated conditions; besides, when using bovine serum, similar results were obtained for coated and uncoated spheres. Finally, suitable mesenchymal stem and osteoblast cells adhesion, proliferation and viability were observed, suggesting good biocompatibility of the nanostructured zirconia films. Taken together, the results shown in this work indicate that zirconia thin films deposited by the PPD method deserve further investigations as low-wear materials for biomedical applications such as total joint replacement.

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

Platelet-rich plasma (PRP) is an innovative approach in the management of cartilage and tendon lesions. It is defined as an autologous blood product with a platelet concentration higher than peripheral blood. The application of PRP on damaged sites could promote tissue regeneration because platelets are a source of several growth factors and other bioactive molecules which may play an important role in tissue homeostasis and healing process. PRP has been applied in different pathologies, both as a conservative injective approach or as “augmentation” during surgical procedures. Studies have been published concerning the treatment of Achilles, patellar, and elbow tendinopathy, as well as rotator cuff lesions and cartilage degeneration of knee, hip and talar osteochondral lesions. The aim of the present manuscript is to review the available scientific evidence regarding clinical application of PRP in treating cartilage and tendon disorders.

The main goals of navigated procedures is to improve the correct position of the graft, and allow the possibility of performing stability testing. Our experience with CAS for ACL reconstruction includes more than 200 cases since 2004, performed with different reconstructive techniques.

PURPOSE: No study, up to now, has examined the effect of arthritis on pathologic subjects using functional flexion axis (FFA). The purpose of this study is to understand whether arthritis affects somehow the FFA evaluation and to assess whether the FFA could be considered a usable reference for implant positioning for osteoarthritic knees. METHODS: Using a navigation system, FFA orientation was evaluated intraoperatively (computed with the mean helical axis method) in three different ranges of motion (0°-120°; 35°-80°; 35°-120°) and in two different planes (coronal and axial), for 111 osteoarthritis patients undergoing total knee arthroplasty. The results were compared with a control group of 60 patients that underwent ACL reconstruction. The angle between the transepicondylar axis (TEA) and FFA was computed. RESULTS: Results showed in arthritic knees on frontal plane, an average difference between TEA and FFA of -2.8° ± 5.0° while on axial plane it was 0.6° ± 4.7°. No statistical difference was found between the three ranges in axial view, whereas some difference was found in frontal view (P < 0.0001). The TEA-FFA angle was not correlated with limb alignment on axial plane, while it was, even if poor, in frontal plane. In the control group, in frontal and in axial view, no statistical difference was found for the angle between TEA and FFA. CONCLUSIONS: FFA can be used as reference for implant positioning in axial plane also in pathologic knees, while for the frontal plane further investigations are required.

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.

Background Return to sport after revision ACL reconstruction is a controversial topic, Several studies reported the results of different techniques and graft in sportsman, presenting an incredibly wide range of return to the same pre-injury activity level, from 0% to 100%. The purpose of this study was to evaluate the clinical outcomes and return to sport rate in young athletes after non-anatomic double-bundle revision ACL reconstruction with Achilles allograft. Hypothesis The present revision technique was effective in terms of stability, return to sport and functional outcomes. Material and methods All the athletes undergone Revision ACL reconstruction with non-irradiated Achilles tendon allograft with a non-anatomical double-bundle technique were included in the study. A splitted Achilles tendon allograft was used to reproduce the anteromedial (AM) bundle using the over-the-top position, while the posterolateral (PL) bundle was reconstructed through a femoral tunnel located in the anatomical PL footprint. Sport activity, knee function with Lysholm score, knee laxity and reinjury or reoperations were evaluated. Results Twenty-six athletes (23 males, 3 females) with a mean age of 23.4 ± 3.6 years were evaluated at a mean follow-up of 6.0 ± 1.6 years. Overall 69% of patients returned to sport both at elite (44%) or county level (56%) after a mean 6.7 ± 1.5 (3–9 range) months. The mean Lysholm score showed a significant improvement from 64.4 ± 8.1 at preoperative status to 83.8 ± 11.3 at final follow-up (P 5 mm side-to-side difference at KT-1000. Therefore, the overall survival rate at mean 6 years follow-up was 81%. Conclusion The ACL revision with a double-bundle technique using Achilles tendon allograft was successful in 81% of athletes at 6 years mean follow-up. Type of study and level of evidence Retrospective case series, level IV.

Background The aim of this article is to review systematically all the literature available on the clinical application of PRP for the treatment of foot and ankle pathologies, to understand its potential and best indications for clinical use. Methods A systematic search of the PubMed database was performed. Research criteria were the following: (1) papers in the English language, (2) dealing with the clinical application of PRP for the treatment of orthopedic-related conditions affecting the foot and ankle district, (3) with I to IV level of evidence, and (4) reporting clinical results. Results A total of 17 studies fulfilled the inclusion criteria. Nine papers dealt with Achilles tendon management, 2 articles with plantar fasciitis, 3 papers with talar osteochondral lesions, 2 with PRP application in total ankle replacement, and 1 article with PRP in foot and ankle fusions. The overall evaluation of the results reported does not clearly demonstrate the potential of PRP treatment in any of the specific fields of application. Conclusions Considering the literature currently available, no clear indications for using PRP in the foot and ankle district emerged. Level of evidence Level IV, systematic review of Level I, II, III and IV studies.

s / Osteoarthritis and Cartilage 22 (2014) S57–S489 S428 771 IN VITRO EFFECTS OF DIFFERENT PLATELET-RICH PLASMA PREPARATIONS ON HUMAN SYNOVIOCYTE RESPONSE A. Roffi, E. Assirelli, G. Filardo, L. Pulsatelli, V. Canella, E. Mariani, E. Kon, M. Marcacci, A. Facchini. Rizzoli Orthopaedic Inst., Bologna, Italy Purpose: Osteoarthritis (OA) is a common disease that will affect almost half the population at some point in their life through pain and decreased functional capacity. Numerous approaches have been proposed, but none can be considered an ideal procedure for the treatment of joint degenerative processes. Among the new therapeutic options, Platelet Rich Plasma (PRP), an autologous blood derived product, is emerging as promising intraarticular treatment for cartilage degenerative lesions. However, results on the potentiality of this biological treatment are still controversial and confounding, due to the lack of well-designed studies and to the different preparation procedures. Aim of this study was to increase knowledge concerning the biological effect of PRP treatment on clinically relevant joint cells. For this purpose, we compared the effect of two different PRP preparations on the expression of a panel of biomolecules by OA cultured synoviocytes. Methods and Materials: Blood collected from 7 volunteers was used to obtain two PRP preparations: a one-spinning procedure, aimed at obtaining a pure platelet concentrate (P-PRP) without leukocytes but with a limited number of platelets, and a two-spinning procedure, aimed at obtaining a higher platelet concentration but with the presence of leukocytes (L-PRP). Synovial tissues were collected from OA patients (Kellgren-Lawrence grade IIIII) undergoing knee replacement surgery. Gene expression analysis of IL-1b, IL-6, IL-8, TNF, MMP-13, TIMP-1, -3, -4, VEGF, TGFb1, IL-10, IL-4,-13, FGF-2, HGF, Hyaluronic acid synthases (HAS)-1, -2, -3 was performed at day 7 (in agreement with weekly clinical administration of PRP) by semiquantitative RT-PCR. HA (Hyaluronic Acid) production was analyzed in culture supernatants by ELISA. Statistical analysis was carried out using the General Linear Model. Results a) White blood cells (WBC) were present only in L-PRP, platelets concentrations were significantly higher in L-PRP than P-PRP. b) HA production and HAS gene expression did not seem to be modulated by PRP c) IL-1b, IL-8 and FGF-2 were significantly induced by L-PRP, whereas HGF was down-modulated by LPRP compared to P-PRP. d) IL-1b and IL-8 expression levels significantly correlated with WBC count and showed a dose-response effect to L-PRP e) HGF mRNA expression showed an inverse correlationwith bothWBC and platelet count. f) MMP-13 expression inversely correlated with WBC number, whereas TIMP-4 inversely correlated with platelet count. h) HAS-2 and HAS-3 had respectively direct and inverse correlation trends with WBC count. Conclusion: Our data in OA synoviocytes indicate that L-PRP is able to sustain long-term up-regulation of pro-inflammatory factors, such as IL-1b, IL-8 and FGF-2 compared to P-PRP, together with a down modulation of HGF and TIMP-4 expression. These last two factors that have been recognized as anti-catabolic mediators in cartilage. Further researches are needed to clarify the influence of different concentrations of WBC on the bioactivity of PRP and their potential beneficial effect. Since WBC-platelet interaction may promote the biosynthesis of other factors that facilitate the resolution of inflammation, such as lipoxins, and given their involvement in immune-response, the optimization of their concentrations in PRP products might lead to minimizing or avoiding the detrimental effects ascribed to leucocytes and exploit their beneficial properties. 772 GENERATING NUCLEUS PULPOSUS-LIKE CELLS FROM HUMAN ADIPOSE STROMAL CELLS: A FIRST STEP TOWARDS THE REGENERATION OF INTERVERTEBRAL DISC P. Colombier y, M. Ruel y, J. Lesoeur y, A. Moreau z, C. Robiou Dupont y, O. Hamel y,x, L. Lescaudron k,y, J. Clouet y,{, J. Guicheux y,#. y INSERMU791LIOAD, Univ. of Dental Sch., Nantes, France; zAnatomopathology Dept., CHU Nantes, Nantes, France; xNeurosurgery Dept., CHU, Nantes, France; kUniv. of Sci.s, Nantes, France; { Pharmacy Dept., CHU, Nantes, France; # PHU 4 OTNN, CHU, Nantes, France Purpose: Intervertebral disc (IVD) degeneration is one of the major causes of low back pain. Whereas some pharmacological and surgical symptomatic treatments are currently available; an efficient, safe and reliable etiological treatment is still lacking. It is now well-established that the Nucleus pulposus (NP) is prematurely affected by degenerative events, mainly starting with the apoptotic death of the NP resident mature cells namely the nucleopulpocytes. In this context, repopulating a damaged NP with functional regenerative cells seems to be a promising approach for long term regeneration of IVD. Since Growth Differentiation Factor 5 (GDF5) plays a crucial role in IVD anabolism and biological activity of nucleopulpocytes, we questioned whether GDF5 may be an efficient tool to drive the nucleopulpogenic differentiation of human Adipose Stromal Cells (hASC). In this context, the aim of the present work was to investigate the effects of supplementing a chondrogenic mediumwith GDF5 on the in vitro production of functional nucleopulpocytes from hASC. Methods: Human ASC were isolated from adipose tissue of 3 informed donors. They have been cultivated in pellets (500.000 cells/pellet) for 28 days in the presence of low oxygen tension (5%) with a chondrogenic medium (TGF-b1 and insulin) enriched or not with GDF5 (100ng/ml). The nucleopulpogenic differentiation of hASC has been evaluated by determining the expression levels of ACAN, COL2A1, PAX1, OVOS2 and CD24 transcripts by RT-qPCR. The levels of the corresponding proteins in hASC pellets have been assessed by immunohistochemistry analyses. In parallel, the specificity of the hASC commitment has been determined by analysing the expression of osteogenic-, adipogenicand chondrogenic-related markers by Taqman Low Density Array. To decipher the role of the Smad pathways during the nucleopulpogenic differentiation, hASC were cultivated in the presence of the GDF5-enriched chondrogenic medium with or without SB505124 (5 mM) or dorsomorphin (5 mM). The respective specificity of these chemical inhibitors was previously analysed by western blot using phospho-specific antibodies against Smad2/3 and Smad1/5/8. Results: Our RT-qPCR and immunohistochemistry data showed that hASC cultivated in the presence of a GDF5-enriched chondrogenic medium expressed nucleopulpocyte markers (ACAN, COL2A1, PAX1, OVOS2 and CD24) at the transcript and protein levels. A time course experiment demonstrated that hASC express nucleopulpocyte markers as early as 21 days of culture. Furthermore, the osteogenic-, adipogenicand chondrogenic-relatedmarkers remain at a barely detectable level of expression. Concerning the role of Smad pathways during the nucleopulpogenic differentiation of hASC, our western blot data demonstrated that SB505124 and dorsomorphin respectively inhibit the phosphorylation of Smad2/3 and Smad1/5/8 and thus respectively block the TGFb and GDF5 canonical pathways. Whereas SB505124 was found to prevent the nucleopulpogenic differentiation of hASC, dorsomorphin did not significantly affect this differentiation process. Conclusions: Our data demonstrate that human ASC cultivated in the presence of a GDF5-enriched chondrogenic medium can be committed towards the nucleopulpocyte lineage. This commitment seems to be reproducible, robust and specific. Our results also suggest that the canonical TGF-b pathway (Smad2/3) plays a pivotal role for the nucleopulpogenic commitment of hASC. Whether the in vitro generation of functional nucleopulpocytes may help us design regenerative medicine strategies remains to be further evaluated in suitable animal models of

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

SummaryObjectiveTo evaluate stability and integrity of bi-layer and three-layer collagen-hydroxyapatite (C-HA) osteochondral scaffolds in a human cadaveric knee exposed to continuous passive motion (CPM) with and without loading and the role of added fibrin glue to improve the press-fit fixation of C-HA scaffolds.DesignOsteochondral lesions (2.0 × 1.5 cm) were chiseled out on both condyles and trochlea in eight human cadaveric knees. A total of 24 bi-layer (5 mm, four in each condyle) or three-layer C-HA scaffolds (8 mm, eight in the trochlea, four in each condyle) were first press-fit implanted and underwent testing with CPM, 90 cycles, 0°–90°. The second set of 24 scaffolds was implanted in cleaned lesions with the addition of fibrin glue. Two knees with fibrin glue fixation were additionally exposed to 15 kg loading, with 30 cycles of CPM, 0°–30°. Then, the knees were reopened and the scaffolds were evaluated using semi-quantitative Drobnic and modified Bekkers scores.ResultsAll but two scaffolds remained in the lesions site throughout CPM. Two implants failed: both were bi-layer osteochondral scaffolds, press-fit implanted at the lateral femoral condyle (LFC). A statistically significant difference was obtained between press-fit and fibrin glue implants with both Drobnic (2.9 ± 0.7 vs 4.3 ± 0.1, P

The paper presents the results of a two year study regarding the use of an innovative drive-train, having a parallel-hybrid structure, in a small scooter, in which a conventional internal combustion engine is coupled with an electric motor for the vehicle propulsion. The developed architecture enhances the maximum vehicle power, by exploiting the braking energy (by recovering it into the provided electrochemical accumulator), and operating the vehicle in zero emission mode for limited ranges. Moreover, it allows for recharging the inner battery from the electric mains, which is extremely appealing in terms of operating costs. According to the simulation results, the hybridization is able to enhance the maximum power of the scooter by 1.1 kW (around 50%), without changing the fuel consumption, and to allow a pure-electric operation with a range of 15-20 km; when the propulsion power comes only from the onboard batteries, and they are recharged from the electric mains, the operation cost per km is around a quarter the cost of corresponding fuel consumption of a vehicle without hybridization

Zur arthroskopischen autologen Chondrozytentransplantation wurde ein biologisch abbaubares, biokompatibles Gerust auf der Basis von Hyaluronsaure verwendet. Alle Patienten wurden nach dem Score der International Repair Cartilage Society prospektiv evaluiert. Die Studie analysiert die klinischen Ergebnisse bei arthroskopisch behandelten Patienten mit 24-monatiger Nachbeobachtung. Wahrend der Behandlungs- und Nachbeobachtungszeit kam es weder zu Komplikationen aufgrund des Implantats noch zu schweren Nebenwirkungen. Nach 12 Monaten verbesserten sich objektiver als auch subjektiver IKDC-Score statistisch signifikant. Es ergab sich kein statistisch signifikanter Unterschied zwischen den klinischen Ergebnissen nach 12 und 24 Monaten. Dieses Verfahren der autologen Chondrozytentransplantation mit Matrix vereinfacht die Operation und ermoglicht eine arthroskopische Implantation mit reduzierter Operationsmorbiditat und Erholungszeit fur den Patienten.

The anterior cruciate ligament (ACL) reconstruction using a double-bundle gracilis and semitendinosus technique guarantees a more anatomic reconstruction and allows the surgeon to avoid the use of hardware for graft fixation. The tendons are harvested, maintaining their tibial insertion. The tibial tunnel is located in the medioposterior part of the ACL tibial insertion. For the femoral tunnel, the guide pin is advanced from anteromedial portal to 10 o'clock position in the medial wall of the lateral condyle and passes until reach the femoral cortex. The exit point in the lateral aspect of the femur should be immediately above the end of the lateral femoral condyle. The tendons are passed over the top. The correct placement is found by palpating the posterior tubercle of the lateral femoral condyle with a finger. The stitches on the free end of the tendons are tied onto the passing suture that is pulled through the knee joint into the over-the-top position. A suture loop is introduced into the joint through the anteromedial portal using a suture passer and then pulled into the femoral tunnel. The stitches on the free end of the tendons are looped again onto the passing suture, which is pulled through the femoral tunnel, knee joint, and tibial tunnel to retrieve the graft from the tibial incision. The combined gracilis and semitendinosus tendons are then tensioned and secured with a transosseous suture knot. This technique attempts to reproduce the kinematic effect of both anteromedial and posterolateral bundle of the ACL.

Cartilage injuries have a high impact on society, and their incidence is increasing over time. For this reason, in the last twenty years numerous treatments have been proposed for the management of such injuries, including conservative and surgical approaches, which can vary from purely reparative procedures to others, characterized also by a regenerative potential. Concerning conservative therapies, they represent the first approach to consider when treating small cartilage defects, but there is no evidence of their ability to alter the degeneration processes of the joint, and they can provide only a short-term pain release. With regard to surgical procedures, they are considered for the treatment of large cartilage lesions or after the failure of conservative management, in order to restore the cartilage surface. Despite the numerous studies performed in this field, the contradictory results reported in the literature prevent to demonstrate the effectiveness of the surgical approach. In this context, the orthopedic surgeon often decide which procedure to perform more as a consequence of his personal experience than following any scientific evidence. This article has the aim to briefly describe the available options for the treatment of cartilage lesions, trying to give an overview of our experience, and to better define the rational and indications of each procedure, thus providing a useful tool for the orthopedic surgeon to decide the procedure to use and when on the basis of scientific data.

Purpose The aim of this review was to analyze the available evidence on the clinical application of this biological approach for the injective treatment of cartilage lesions and joint degeneration, together with preclinical studies to support the rationale for the use of platelet concentrates, to shed some light and give indications on what to treat and what to expect from intra-articular injections of platelet-rich plasma (PRP). Methods All in vitro, in vivo preclinical and clinical studies on PRP injective treatment in the English language concerning the effect of PRP on cartilage, synovial tissue, menisci, and mesenchymal stem cells were considered. A systematic review on the PubMed database was performed using the following words: (platelet-rich plasma or PRP or platelet concentrate or platelet lysate or platelet supernatant) and (cartilage or chondrocytes or synoviocytes or menisci or mesenchymal stem cells). Results Fifty-nine articles met the inclusion criteria: 26 were in vitro, 9 were in vivo, 2 were both in vivo and in vitro, and 22 were clinical studies. The analysis showed an increasing number of published studies over time. Preclinical evidence supports the use of PRP injections that might promote a favourable environment for joint tissues healing. Only a few high-quality clinical trials have been published, which showed a clinical improvement limited over time and mainly documented in younger patients not affected by advanced knee degeneration. Conclusions Besides the limits and sometimes controversial findings, the preclinical literature shows an overall support toward this PRP application. An intra-articular injection does not just target cartilage; instead, PRP might influence the entire joint environment, leading to a short-term clinical improvement. Many biological variables might influence the clinical outcome and have to be studied to optimize PRP injective treatment of cartilage degeneration and osteoarthritis. Level of evidence IV.

Platelet-rich plasma (PRP) has been introduced in the clinical practice to treat a growing number of different musculoskeletal pathologies. It is currently applied in the treatment of Achilles and patellar tendinopathies, which are common sport-related injuries very challenging to manage. Aim of the present paper was to review systematically the available clinical evidence concerning the application of PRP in the treatment of patellar and Achilles tendinopathy. A systematic review of the literature was performed according to the following inclusion criteria for relevant articles: (1) clinical reports of any level of evidence, (2) written in the English language, (3) with no time limitation and (4) on the use of PRP to treat conservatively Achilles and patellar tendinopathy. Twenty-two studies were included and analyzed. Two studies on patellar tendinopathy were randomized controlled trials (RCTs), whereas just one RCT was published on Achilles tendon. All the papers concerning patellar tendon reported positive outcome for PRP, which proved to be superior to other traditional approaches such as shock-wave therapy and dry needling. In the case of Achilles tendon, despite the encouraging findings reported by case series, the only RCT available showed no significant clinical difference between PRP and saline solution. The main finding of this study was the paucity of high-level literature regarding the application of PRP in the management of patellar and Achilles tendinopathy. However, the clinical data currently available, although not univocal, suggest considering PRP as a therapeutic option for recalcitrant patellar and Achilles tendinopathies.

The primary aim of this work was to evaluate the neurovascular network of the pes anserinus (PA) at its tibial insertion because the PA is often used for anterior cruciate ligament (ACL) reconstruction. Four fresh cadaver knees were injected with India ink gelatin solution and the arteries that supply blood to the PA were identified; microscopic studies of vessels and nerve fibers were also performed. Superficial and deep branches of the inferior medial genicular artery contribute to an arterial arch that courses deep to the PA insertion. A widespread array of small vessels and nerve fibers penetrate the PA insertion and course along the length of the gracilis and semitendinosus tendons. Computer analysis revealed that the mean diameter of the vessels decreased from 2201 microm at the insertion to 661 microm midway along the length of the tendon (mean tendon length = 17 cm; range = 13-21 cm); the cross-sectional area of the vessels per histologic section decreased from 336.37-137.05 microm(2). This study demonstrates that the PA insertion is well vascularized and richly innervated and that these morphological features continue along the length of the tendons.