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Background: The accuracy of the coronal alignment corrections using conventional high tibial osteotomy (HTO) falls short, and multiplanar deformities of the tibia require consideration of both the coronal and sagittal planes. Patient-specific instrumentations have been introduced to improve the control of the correction. Clear evidence about customized devices for HTO and their correction accuracy lacks. Methods: The databases PUBMED and EMBASE were systematically screened for human and cadaveric studies about the use of customized devices for high tibial osteotomy and their outcomes concerning correction accuracy. Furthermore, a 3D-printed customized system for valgus HTO with three pilot cases at one-year follow-up was presented. Results: 28 studies were included. The most commonly used custom-made devices for HTO were found to be cutting guides. Reported differences between the achieved and targeted correction of hip-knee-ankle angle and the posterior tibial slope were 3° or under. The three pilot cases that underwent personalized HTO with a new 3D-printed device presented satisfactory alignment and clinical outcomes at one-year follow-up. Conclusion: The available patient-specific devices described in the literature, including the one used in the preliminary cases of the current study, showed promising results in increasing the accuracy of correction in HTO procedure.

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.

Background Bone defects during revision procedures for failed UKA represent a challenge even for the most experienced surgeons; therefore, an accurate preoperative planning remains essential to prevent dramatic scenarios in the surgical theatre. Hypothesis Our hypothesis is that bearing thickness used in original UKA represents a reliable predictor of severe tibial bone loss, requiring a metallic augment or constrained implant, during revision to TKA. Patients and methods Forty-two patients who underwent a total knee arthroplasty from failed UKA were identified from our institutional database and evaluated clinically using the Knee Society Score (KSS). A multivariate logistic regression analysis was performed using the presence of tibial augments or the need of varus-valgus constrained (VVC) prosthesis as depend variables, and patients’ gender, age at revision procedure, side (medial or lateral), UKA tibial tray (all-polyethylene or metal back), bearing thickness (composite thicknesses of the metal-backed tray and insert or all-polyethylene tibial component ≤ 8 mm or more than 8 mm) and cause of failed UKA as independent variables. Results A posterior-stabilized prosthesis was used in 27 cases (64.3%). An augment was necessary in 12 patients (28.6%). Initial bearing thickness greater than 8 mm was associated with greater likelihood of a VVC implant (OR = 11.78, 95% CI, 1.6583 to 83.6484, p = 0.0137) and a tibial augment (OR = 9.59, 95% CI, 1.327 to 69.395, p = 0.0251). Tibial tray design, patients’ gender or age during revision surgery, side or cause of failure were not associated to increased risk of augmentation or constrained implants. Discussion Surgeons should be aware of the particular challenges that the conversion of a UKA to a TKA presents and be prepared to address them intraoperatively, with particular care to proper bone loss manage. Satisfying results can be achieved at mid-to-long term follow-up, if these procedures are planned accurately, and a precise analysis of failed UKA components, in particular bearing thickness, represents a helpful support in this context. Level of evidence IV, retrospective case series.

Background: Failure of anterior cruciate ligament (ACL) reconstruction or an injury to the ACL in the contralateral knee represents a devastating event for patients, especially those young and physically active. However, controversies are still present regarding long-term failure rates and risk factors. Purpose: To assess the long-term rate of ipsilateral graft failure and contralateral ACL injuries after ACL reconstruction performed at a single center using the same surgical technique with a hamstring autograft and to investigate the effect of sex, age, and preinjury activity level as predictors of second ACL injuries. Study Design: Case series; Level of evidence, 4. Methods: The study cohort consisted of 244 consecutive patients (mean age, 30.7 years) who underwent ACL reconstruction with a single bundle plus lateral plasty technique using the hamstring tendon between November 2007 and May 2009. The number of subsequent ACL injuries (ipsilateral ACL revision or contralateral ACL reconstruction) was determined at a minimum follow-up of 10 years. Survivorship of either knee and subgroup analysis included sex, age, preoperative Tegner activity level, timing of ACL reconstruction, body mass index, and smoking status. Results: Ipsilateral ACL revision was performed in 8 (3.4%) patients and contralateral ACL reconstruction in 19 (7.8%) patients. Only 1 patient had both ipsilateral and contralateral injuries. No predictors were found for ipsilateral ACL revision, while age Conclusion: In the long term, a second injury to either the ipsilateral or the contralateral knee in young and active populations could reach 40%, with a more than double-fold risk of contralateral ACL reconstruction compared with ipsilateral ACL revision.

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. 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). 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. 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. Retrospective cohort study, Level III.

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.

Background Two-stage revision for periprosthetic knee infection is challenging in cases of massive bone loss and instability. The present study aims to describe our experience with an alternative technique of reinforced cement spacer, usually necessary in these situations, focusing on its advantages and clinical results. Methods We retrospectively identified all patients who underwent a two-stage revision for periprosthetic knee infection using two intramedullary Kuntscher nails as reinforcement from January 2010 to September 2018. From each medical record, we extracted the type of explanted prosthesis, isolated micro-organism, number of cement spacers before index procedure (and related episodes of spacer dislocation) and final treatment. Results Twelve patients were identified, mean age of 64.0 years (range 39–85). In four of them, the reinforced spacer was used twice for persistent infection, with a total of 16 procedures performed and no cases of dislocation. Ten patients were finally treated with reimplantation or arthrodesis with intramedullary nails, whereas an above-knee amputation was necessary for two patients. Infection was eradicated in 10 patients out of 12 (83%) at a mean follow up of 34.3 months (range 10–62). Conclusions This technique is an effective alternative to traditional spacers in cases of massive bone loss, producing a mechanically stable joint and preserving adequate tissue tensions. The construct is technically easy to perform and, not less importantly, to remove during stage 2. Further studies, with larger groups, are necessary to determine its validity.

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 (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.

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.

The aim of the present study is to examine the readmission rate within 90 days of a cohort of patients, who underwent an arthroscopic anterior cruciate ligament (ACL) reconstruction with a lateral extraarticular tenodesis, from a single highly specialized sports traumatology department. From our institutional database, we identified 2,559 patients (78.5% males and 21.5% females, with a mean age at surgery of 30.9 ± 11.5 years) who underwent primary ACL reconstruction with the same “over-the-top” technique plus lateral extraarticular tenodesis (LET) from January 2010 to December 2017. From this count, we extracted all patients who were readmitted within 90 days and focused on causes of readmission and reoperation rate. Moreover, a multivariate logistic regression was performed to identify possible variables, such as gender, age, and concomitant meniscus surgery, which could predict the risk of early readmission. From the aforementioned cohort, 58 patients (2.27%) were readmitted within 90 days from surgery after a mean time of 31 ± 23 days. The most common cause of readmission was fever and knee swelling (0.78%), followed by superficial infection (0.63%), deep infection (0.55%), and joint stiffness (0.23%). The patients' age and meniscal lesions requiring concomitant arthroscopic treatment were found to be correlated to an increased risk of early readmission. Superficial infections were more common in female patients (odds ratio [OR] = 3.01), whereas the meniscal treatment was also a significant risk factor specifically for deep infections (OR = 3.56). In conclusion, this technique of arthroscopic ACL reconstruction with LET showed a low readmission rate within 90 days from surgery. However, patients and physicians should be aware of the risk of serious complications, such as deep and superficial infections, mostly in female patients and in cases of concurrent meniscal treatments. This is a Level IV, retrospective case series study.

CASE: A 15-year-old woman with multiple arthroscopic procedures for left lateral discoid meniscus since the age of 9 presented with pain, swelling, and mechanical symptoms. A meniscal allograft transplantation (MAT) and lateral opening-wedge femoral osteotomy was performed. At the 6-year follow-up, the patient presented a visual analog scale (VAS) score of 0, subjective International Knee Documentation Committee (IKDC) of 88, and Lysholm of 95. At 15-year follow-up, the VAS score was 0, subjective IKDC 85.1, and Lysholm 86. CONCLUSIONS: MAT associated with femoral osteotomy was an effective procedure in this patient with pain and functional limitation after total meniscectomy in the setting of discoid meniscus and valgus malalignment. Good clinical and magnetic resonance imaging-related outcomes were achieved at the intermediate and long-term follow-up.

Background Bone defects during revision procedures for failed UKA represent a challenge even for the most experienced surgeons; therefore, an accurate preoperative planning remains essential to prevent dramatic scenarios in the surgical theatre. Hypothesis Our hypothesis is that bearing thickness used in original UKA represents a reliable predictor of severe tibial bone loss, requiring a metallic augment or constrained implant, during revision to TKA. Patients and methods Forty-two patients who underwent a total knee arthroplasty from failed UKA were identified from our institutional database and evaluated clinically using the Knee Society Score (KSS). A multivariate logistic regression analysis was performed using the presence of tibial augments or the need of varus-valgus constrained (VVC) prosthesis as depend variables, and patients’ gender, age at revision procedure, side (medial or lateral), UKA tibial tray (all-polyethylene or metal back), bearing thickness (composite thicknesses of the metal-backed tray and insert or all-polyethylene tibial component ≤ 8 mm or more than 8 mm) and cause of failed UKA as independent variables. Results A posterior-stabilized prosthesis was used in 27 cases (64.3%). An augment was necessary in 12 patients (28.6%). Initial bearing thickness greater than 8 mm was associated with greater likelihood of a VVC implant (OR = 11.78, 95% CI: 1.6583 to 83.6484, p = 0.0137) and a tibial augment (OR = 9.59, 95% CI: 1.327 to 69.395, p = 0.0251). Tibial tray design, patients’ gender or age during revision surgery, side or cause of failure were not associated to increased risk of augmentation or constrained implants. Discussion Surgeons should be aware of the particular challenges that the conversion of a UKA to a TKA presents and be prepared to address them intraoperatively, with particular care to proper bone loss manage. Satisfying results can be achieved at mid-to-long-term follow-up, if these procedures are planned accurately, and a precise analysis of failed UKA components, in particular bearing thickness, represents a helpful support in this context. Level of evidence IV, retrospective case series.

Purpose: To assess, using model-based dynamic radiostereometric analysis (RSA), the biomechanical behaviour of a new design posterior-stabilized (PS) fixed-bearing (FB) total knee arthroplasty (TKA) in vivo while patients performing two common motor tasks. The hypothesis was that model-based dynamic RSA is able to detect different behaviour of the implant under weight-bearing and non-weight-bearing conditions. Methods: A cohort of 15 non-consecutive patients was evaluated by dynamic RSA 9months after TKA implantation. The mean age of patients was 73.4 (65–72) years. The kinematic evaluations were performed using an RSA device (BI-STAND DRX 2) developed in our Institute. The patients were asked to perform two active motor tasks: sit-to-stand in weight-bearing condition; range of motion (ROM) while sitting on the chair. The motion parameters were evaluated using the Grood and Suntay decomposition and the low-point kinematics methods. Results: The dynamic RSA evaluation showed a significant difference (p < 0.05) between the biomechanical behaviour of the prosthesis during the two motor tasks. When subjected to the patient weight (in the sit-to-stand) the low point of the medial compartment had a shorter motion (5.7 ± 0.2mm) than the lateral (11.0 ± 0.2mm). This realizes a medial pivot motion as in the normal knee. In the ROM task, where the patient had no weight on the prosthesis, this difference was not present: the medial compartment had a displacement of 12.7 ± 0.2mm, while the lateral had 17.3 ± 0.2mm. Conclusions: Model-based RSA proved to be an effective tool for the evaluation of TKA biomechanics. In particular, it was able to determine that the fixed-bearing posterior-stabilized TKA design evaluated in this study showed a medial pivoting movement under weight-bearing conditions that was not present when load was not applied. Under loading conditions what drives the pattern of movement is the prosthetic design itself. By the systematic use of this study protocol future comparisons among different implants could be performed, thus contributing significantly to the improvement of TKA design. Level of evidence: IV.

PURPOSE: "Early Osteoarthritis (EOA)" has been defined combining clinical, imaging and surgical parameters, with the aim to identify patients in early degenerative phases, who might benefit from the use of available regenerative procedures. Aim of this first clinical trial is to prospectively evaluate the results obtained in a group of patients meeting the inclusion criteria of "EOA" as proposed by the ESSKA Cartilage Committee, and surgically treated with the implantation of a multi-phasic osteochondral scaffold. METHODS: 23 patients were prospectively evaluated at 12 and 24 months of follow-up. Etiology of the chondral or osteochondral defect was rated as microtraumatic or degenerative in 18 cases, and traumatic in 5 cases. Patients included were complaining of clinical symptoms like knee pain and affected by chondral and osteochondral lesions located at the femoral condyles or trochlea and MRI findings demonstrating articular cartilage degeneration and/or meniscal degeneration and/or subchondral bone marrow lesions. RESULTS: All patients increased significantly in any clinical score adopted. The IKDC subjective score increased from 42.8 ± 13.8 at basal evaluation to 74.3 ± 17.4 at 12 months' (p < 0.0005), being stable (74.9 ± 20.4) up to the final follow-up of 24 months. Tegner score showed a statistically significant improvement in sports activity from 3.3 ± 2.7 pre-operative to 4.6 ± 2.2 at 12 months (p < 0.005), with a slight improvement to the final evaluation (4.7 ± 2.1; n.s.). However, the activity level was significantly lower than the pre-injury one (6.1 ± 2.6; p = 0.004). A significant difference was shown between patients younger versus older than 40 years, with younger patients had better clinical improvement (76.0 ± 18.6 vs 45.1 ± 38.8 respectively, p = 0.037). CONCLUSIONS: The implantation of a multi-phasic osteochondral scaffold represents a good option after failure of conservative management for Early OA patients, where younger age represent an important factor for a better outcome. Longer follow-up is needed to evaluate the benefit over time. LEVEL OF EVIDENCE: IV, case series.

BACKGROUND: Return to sport and to pre-injury level represents an important outcome after both primary and revision anterior cruciate ligament (ACL) reconstructions. PURPOSE: The aim of the present meta-analysis was to determine the return to sport rate after revision ACL reconstruction. MATERIAL AND METHODS: A systematic search was performed of the MEDLINE, Embase and the Cochrane Central Register of Controlled Trials Databases. All the studies that reported return to sport, return to pre-injury sport level and return to high level/competitive sport was considered for the meta-analysis. The overall pooled mean of post-operative knee laxity and pooled rate of positive pivot-shift and objective International Knee Documentation Committee (IKDC) categories was calculated as well. RESULTS: Overall, 472 abstracts were identified and screened for inclusion and only 16 studies reported the rate of return to any level of sport activity at the final follow-up of 4.7 years (range 1.0-13.2 years), showing a pooled rate of 85.3% (CI 79.7 to 90.2). The return to pre-injury sport level was achieved in 53.4% (CI 37.8 to 68.7) of cases. Normal or quasi-normal objective IKDC, less than 5 mm of side-to-side difference at arthrometric evaluations and grade I-II pivot-shift test were reported in 84%, 88% and 93% patients, respectively. CONCLUSIONS: In spite of almost 8 patients out of 10 returning to sport after revision ACL reconstruction and showing good stability, only half of the patients returned to the same pre-injury sport level. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

none 17 no Prosthetic joint infection (PJI) is among the most-severe complications of a total joint arthroplasty. Identification of the causal organism is of paramount importance for successful treatment, and sonication of implants may aid in this identification. Dithiothreitol (DTT) treatment has been proposed as an alternative to sonication to improve diagnosis, reduce costs, and improve reliability of the procedure, but its efficacy remains poorly characterized. mixed Sambri, Andrea; Cadossi, Matteo; Giannini, Sandro; Pignatti, Giovanni; Marcacci, Maurilio; Neri, Maria Pia; Maso, Alessandra; Storni, Elisa; Gamberini, Simonetta; Naldi, Susanna; Torri, Arianna; Zannoli, Silvia; Tassinari, Martina; Fantini, Michela; Bianchi, Giuseppe; Donati, Davide; Sambri, Vittorio Sambri, Andrea; Cadossi, Matteo; Giannini, Sandro; Pignatti, Giovanni; Marcacci, Maurilio; Neri, Maria Pia; Maso, Alessandra; Storni, Elisa; Gamberini, Simonetta; Naldi, Susanna; Torri, Arianna; Zannoli, Silvia; Tassinari, Martina; Fantini, Michela; Bianchi, Giuseppe; Donati, Davide; Sambri, Vittorio

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

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 The restoration of the physiological femoro-tibial joint line (JL) is important to obtain a good outcome in revision total knee arthroplasty (RTKA). However, its assessment is challenging. The ratio of the distance between the adductor tubercle (AT) JL (ATJL) and the trans-epicondylar femoral width (FW) was proposed as a reliable method. The purpose of this study was to check whether this ratio is a reliable tool to restore the prosthetic JL height in challenging prosthetic revision cases. Methods Twenty-one patients (mean age 65.8 years) were recruited. During surgery, FW was measured and ATJL distance was calculated using 0.53 (SD 0.03) as the ratio. After implant positioning, the obtained ATJL line was measured to verify the accuracy of the surgical procedure. Thirteen patients presented a healthy contralateral knee: a comparative radiograph examination was performed to verify the appropriateness of the restored JL height. Results The intra-operatively calculated ATJL was not significantly different with respect to the measured ATJL obtained after prosthetic component implantation. The comparative analysis between the restored JL and the JL of the contralateral not operated knee was also not statistically significant, thus confirming the appropriateness of the restored JL height. Conclusions This study shows that the method which uses an AT to JL distance/FW ratio to determine the JL level, previously applied in primary TKA, is valid when using intra-operatively acquired measurements in RTKA. This is clinically relevant since it represents a reliable tool which helps surgeons to restore the JL level in challenging prosthetic revision cases.

The purposes of this paper are to summarize the concepts relating to the use of a combined intra-articular and extra-articular reconstructive procedure in the arthroscopic treatment of a torn ACL and to review several operative techniques utilizing gracilis and semitendinosus tendons that are currently in use to treat this instability. The highly satisfactory results obtained over the time show that a combination of intra- and extra-articular procedures for ACL reconstruction is a valid surgical option.

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.

Purpose: To determine the medium-term implant survivorship, the clinical results and the failure mechanisms of a novel unicompartmental arthroplasty for uncemented resurfacing of the medial tibio-femoral compartment. Methods: Seventy-six consecutive patients were prospectively evaluated with a mean final follow-up of 6 years (SD 5.3 months). In 44 patients, the diagnosis was osteoarthritis, and in 32 patients, it was avascular necrosis of the medial femoral condyle. The Hospital for Special Surgery Score was used for objective clinical evaluation, and a self-administered visual analogue scale was used to quantify residual pain at each observation point. Implant survivorship was determined assuming revision for any reason as endpoint. Results: Nineteen patients were revised (6 with osteoarthritis and 13 with avascular necrosis of the medial femoral condyle). The mean interval time from index surgery to revision was 11.2 months (SD 4.66 months). Implant survivorship was higher in patients with osteoarthritis with respect to those with avascular necrosis of the medial femoral condyle (p = 0.018). Aseptic loosening was the most frequent failure mechanism. Femoral component loosening was reported in five patients and tibial component loosening was reported in other six patients. Assuming revision for any reason as endpoint, an implant survivorship of 74.3 % at 6-year follow-up was determined. In the remaining 57 patients, satisfactory clinical results were obtained. Hospital for Special Surgery Score and visual analogue scale for residual pain showed significant improvements (p

Purpose To compare patient-reported and clinician-reported outcomes, and radiographic results between patients who had had revision ACL reconstruction and those who had had primary ACL reconstruction. Design Systematic review and meta-analysis Data sources The MEDLINE, CINAHL, EMBASE and SPORTDiscus electronic databases were searched on 6 August 2015, using 3 main concepts: (1) revision ACL reconstruction, (2) primary ACL reconstruction and (3) treatment outcomes. Eligibility criteria for selecting studies Articles that compared patient-reported or clinician-reported outcomes or radiographic results between patients who had had revision ACL reconstruction and those who had had primary surgery with a minimum of 2 years follow-up were included. The outcomes evaluated were the Lysholm Knee Scoring Scale, objective International Knee Documentation Committee (IKDC) classification, Tegner Activity Scale, side-to-side difference in anterior tibial translation measured with KT-1000/2000 arthrometer, pivot shift test, tibiofemoral osteoarthritis grading on plain radiographs and subsequent knee surgeries. Results 8 studies (300 revision ACL reconstructions and 413 primary ACL reconstructions) were included in the meta-analysis. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores (mean difference: 7.8 points), had inferior clinician-reported knee function as assessed with the objective IKDC classification (IKDC category A: 27% vs 57%; IKDC category C or D: 22% vs 8%) and pivot shift test (grade II or III: 7% vs 2%), and more radiographic evidence of tibiofemoral osteoarthritis (50% vs 25%) compared with patients who had had primary surgery. Conclusions Revision ACL reconstruction restored similar anterior-posterior knee laxity compared with primary ACL reconstruction. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores, had inferior clinician-reported knee function and more radiographic signs of tibiofemoral osteoarthritis compared with patients with primary ACL reconstruction.

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.

A variety of graft sources have been used for ACL reconstruction to improve functions and kinematics in ACL deficient knees. The two most commonly used autogenous grafts are the central third of the patellar tendon and the hamstring tendon constructs. The choice of different grafts and different construct influence the final clinical outcome of ACL reconstruction. The 3 groups, of 25 patients each, were generated by choosing the technique (PT tendon, 4 strand hamstring, and single hamstring plus extraarticular plasty) to utilize and followed for 5 years, with an alternate systematic sampling. Our comparison has shown significant kneeling pain in the patellar tendon with respect to the groups with hamstrings techniques. Single hamstring plus extraarticular plasty achieved subjective score significantly higher with respect to the other two groups as well as for the time to resume sport. The study confirms that patellar tendon and hamstring can be equivalent options for ACL reconstruction. This study demonstrated that a superior outcome as far as subjective clinical findings were concerned, was obtained in group III. Patients in the latter group were also able to return to sports sooner than those in the bone-patellar tendon graft group and the four-strand hamstring group.

Posterolateral corner structures functionally interact with the ACL. The aim of this study was to investigate the capability of an isolated ACL reconstruction control laxity parameters in a knee with combined ACL and PLC and the increase in terms of laxity produced by the resection of the PC in an ACL-deficient knee. An in vitro cadaveric study was performed on seven knees. The joints were analysed in the following conditions: intact, after ACL resection, after popliteus complex resection, after ACL reconstruction and after LCL. Testing laxity parameters were recorded with an intra-operative navigation system and defined as: AP displacement at 30° and 90° of flexion (AP30 and AP90) applying a 130 N load and IE at 30° and 90° of knee flexion with a 5 N load. Sectioning the ACL significantly increased the AP30 at 30° and 90° of knee flexion (p

The purpose of this study was to evaluate the results at minimum 2 years follow-up of our original hamstrings technique, with intra and extra articular ACL plasty, followed by an aggressive rehabilitation program. Forty young sports practising patients were prospectively selected. IKDC score, Lysholm scale score as well as KT 2000 and isokinetic tests with a Lido machine (Lido CA) were used for patient evaluation. Ninety percent of the patients had a negative Lachman test and 85% experienced no pivot shift. Valgus rotation was 1+ in 22.5% of the cases. KT 2000 evaluation showed a similar trend in the three tests performed, with an average injured/uninjured difference of 2.1 mm. The results confirm our original hamstrings technique efficacy and its low morbidity. Patients with residual valgus laxity in relation to partial MCL tears had significantly higher KT parameters and consequently less favourable outcome. An aggressive rehabilitation reduces sensitively the sport recovery time without affecting knee stability.

Numerous surgical procedures have been developed and used for anterior cruciate ligament (ACL) reconstruction. Patellar tendon is probably the most common graft used, but gracilis and semitendinous tendons present some interesting advantages: small incision, large graft when doubled, characteristics close to ACL, rapid harvest. We describe a combined intra- and extra-articular arthroscopic ACL reconstruction using hamstring tendons which includes some original steps. The tendons are harvested, leaving the distal insertion intact, and sutured together. After drilling of the tibial tunnel, an over-the-top arrangement is formed, creating a groove in the posterolateral aspect of the femur. The tendons are then fixed with double staples in the groove, and their remaining part is fixed distally to Gerdy's tubercle passing under the fascia, but over the lateral collateral ligament (LCL). This technique ensures sufficient strength in the graft and permits correction of any associated instability, because of the presence of the extra-articular portion of the tendons. Furthermore, the over-the-top arrangement reduces trauma and possible pitfalls related to tunnel construction and permits isometry of the extra-articular portion to be established. Forty patients involved in sports activity were prospectively selected and evaluated at a minimum 2 years' follow-up. IKDC score and Lysholm score were used for clinical evaluation, and the KT-2000 was used for instrumental laxity measurements. Resumption of sport and time to that point were recorded as well as Tegner activity score. We had 92.5% normal and fairly normal knees according to IKDC score and only 7.5% abnormal knees. Mean Lysholm score was 95. Mean Tegner score was 7.2. KT-2000 showed a mean injured/uninjured difference of 2.1 mm. In all, 90% of patients resumed sports at the same level, 67.5% in 3-4 months and 27.5% in 4-6 months. The highly satisfactory results of this series with no major complications confirm the reliability of this technique and the possibility of guaranteeing functional behaviour in the knee.

PURPOSE: The goal of this study was to compare three types of mobile-bearing posterior cruciate ligament (PCL)-sacrificing TKA. The hypothesis was that the three designs provide differences in flexion stability and femoral rollback and improved clinical score at 2-year follow-up. METHODS: Three groups of patients, divided according to implant design, were analysed retrospectively. All operations were guided by a non-image-based navigation system that recorded relative femoral and tibial positions in native and implanted knees during: passive range of motion and anterior drawer test at 90° flexion. WOMAC, KSS and SF36 scores were collected pre-operatively and at 2-year follow-up. RESULTS: There are no differences in kinematic or clinical performance of the three implants, except for the antero-posterior translation during stress test in flexion: only Cohort B had comparable pre- and post-operative laxity test values (p < 0.001). All three TKA designs allowed to maintain pre-operative tibial rotation pattern through all range of knee flexion. All clinical scores of the three patient cohorts were significantly improved post-operatively compared to the pre-operative values (p < 0.001). Moreover, we found no differences among post-operative results of the three designs. CONCLUSION: Despite design variations, mobile-bearing PCL-sacrificing TKA reproduces femoral rollback and screw-home with little or no difference in clinical or functional scores at a follow-up of 2 years. LEVEL OF EVIDENCE: III.

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

Background:A consensus on the treatment of combined anterior cruciate ligament (ACL) and posterolateral corner (PLC) injuries is still lacking.Purpose:To review the available literature on the management of these combined lesions to investigate the influence that injuries of knee posterolateral structures play in the outcome of an ACL lesion.Study Design:Systematic review; Level of evidence, 4.Methods:A comprehensive search was performed on PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: “posterolateral corner,” “plc,” “posterolateral instability,” “posterolateral injury,” “anterior cruciate ligament,” and “acl.”Results:A total of 6 studies involving 95 patients were included. For those with PLC lesions, 14 patients were treated nonoperatively, 9 underwent an early anatomic repair, while the remaining 72 underwent a reconstruction. In all 95 patients, an ACL reconstruction was performed. Sixty-seven of the 72 patients who underwent a PLC reconstruction were assessed for anteroposterior laxity, with a mean side-to-side difference of 1.5 ± 1.1 mm. Evaluated by the objective International Knee Documentation Committee (IKDC) Knee Form, 88% of the patients who underwent a PLC reconstruction were graded as good/excellent (A/B). The 9 patients who underwent an early surgical repair of the PLC lesion were evaluated by means of the objective IKDC score, with 3 patients (33%) graded as good/excellent (A/B), and by means of a clinical evaluation, with 5 of 9 patients (56%) graded as 1+ for varus laxity. For the 14 patients who were managed nonoperatively for PLC injuries, the only clinical score available was the subjective IKDC score, with a mean value of 80.5 (87.8 for the 6 patients with type A PLC injuries and 75.0 for type B PLC injuries).Conclusion:There is a paucity of literature focused on the management of combined ACL and PLC injuries. Combined ACL and PLC reconstruction seems to be the most effective approach to these combined lesions. However, future work is needed to explore the long-term outcome of the different treatment options.

Overweight patients are often considered poor candidates for total knee arthroplasty (TKA). A retrospective study of this was done on 47 osteoarthritic knees treated by TKA without patella resurfacing between March 1991 and June 1993. The Hospital for Special Surgery (HSS) rating system was used for clinical evaluation, and radiographs to study the degree of osteoarthritis and radiolucency. Correlations between overweight, range of motion (ROM) and stage of patellar damage and other measured variables (HSS score, patellar pain and radiolucency) were studied. Overweight was not correlated with HSS score, radiolucency or patellar pain. ROM was significantly correlated with patellar pain and HSS score, with better results in patients with ROM between 90 degrees and 110 degrees. Therefore, we believe that TKA in osteoarthritic knees can lead to successful results, even in active or overweight patients.

Arthroscopic treatment was performed on 71 patients with recurrent shoulder dislocations; all of the patients ahd monoplanar anterior instability attributable to arthroscopically diagnosed Bankart lesion. Of the 71 operations, 29 were performed using the original Caspari technique (follow-up, 59 months), and 42 were performed after modifications made in the original technique (follow-up, 38 months), notably improved preparation of the capsular reinsertion zone and increase in the number of monofilament points and their anchorage directly to the bone, on the spine of the scapula. We compared the results obtained in these two differently treated groups, taking into account several factors in the patient's history and clinical condition. These included the number of dislocation episodes before the operation, as well as clinical findings regarding stability, movement, function and pain (Rowe scale score), contralateral shoulder laxity, level of preoperative versus postoperative athletic activity, and postoperative recurrence rate. In the Caspari-treated group, we obtained 66% satisfactory results compared with the 90% obtained in the second group. The recurrence rate was 27% in the first group compared with 4.8% in the second group. These data were statistically significant. No correlation was found between preoperative number of dislocations and recurrence rate, nor for contralateral shoulder laxity. No significant difference was found regarding resumption of sport activity in the two groups. Our data indicate that, with accuracy in patient selection and effective surgical technique, the recurrence rate can be reduced, and results similar to those of the arthrotomic technique may be obtained.

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. © 2010 Springer-Verlag.

We assessed 30 patients with a cemented TKR implant (Interax ISA (R), Stryker Orthopaedics) at 1 and 3 years follow-up. We wanted to ascertain whether knee alignment was maintained during the critical period of follow-up in meniscal-bearing PCL-retaining TKR patients and test if correlations exist between alignment variations in the coronal plane and preoperative varus/valgus deformity or tibial component position and migration with respect to the tibia. Lower limb alignment was evaluated by measuring the angle between the tibia and femur anatomical axis directly from the antero-posterior radiographs and the tibial component position with respect to the tibial anatomical axis. The tibial component varus/valgus migration in the tibia was measured by roentgen stereophotogrammetric analysis, The results showed that at 3 years follow-up 40% of patients presented an alignment variation of over 3 degrees. The recurrent deformity was not correlated with the preoperative deformity, nor with the tibial component position with respect to the tibial shaft nor with its migration. After total knee arthroplasty coronal axial variation is a common finding and it depends on the overall limb muscles and ligaments adaptation to prosthetic constraints.

Autologous chondrocyte implantation (ACI) is an effective means of treating symptomatic articular cartilage defects. This two-stage cartilage repair strategy relies on the cultured expansion of harvested chondrocytes; these cells are subsequently reimplanted into the host defect and covered (periosteum, collagen patch). The ACI technique has been shown by many authors to result in improved clinical outcomes by facilitating the creation of a hyaline-like cartilage repair tissue. However, it has been demonstrated that defect fill can be variable, and that the procedure itself is technically demanding. Over the past few years, so called “second generation” ACI techniques have been available for clinical use in many parts of the world. These second generation techniques rely on the combination of autologous chondrocytes with absorbable scaffolds. It is believed that the addition of a stable matrix scaffold facilitates the creation of a more hyaline-like cartilage repair tissue. We describe, herein, such a technique. The Hyalograft C implant has been used to treat symptomatic cartilage defects at our institution for many years. This implant consists of autologous chondrocytes that are seeded on a hyaluronan-based scaffold. Implantation of the Hyalograft C scaffold simplifies the method by which autologous chondrocytes may be used to repair a cartilage defect. Moreover, we believe this is the first method by which autologous chondrocytes may be implanted using minimally invasive arthroscopic techniques. The Hyalograft C implant effectively treats symptomatic cartilage defects in a manner that is less morbid, simpler, and more predictable than first-generation ACI methods.

Meniscal substitution is a fundamental procedure to prevent osteoarthritis of the knee after massive meniscectomy. Stone, Steadman and Rodkey have developed a bioreadsorbable collagen matrix (CMI) which acts as a scaffold to restore the original medial meniscal. The objective of this study was to prospectively evaluate the results of CMI implantation at a follow up from a minimum of 6 to a maximum of 8 years. Eight patients (mean age 25) were evaluated at a final observation point from 6 to 8 years after CMI implantation. Inclusion criteria were an irreparable meniscal tear or a previous meniscectomy involving the medial meniscus. Follow up evaluation included Cincinnati Knee Rating Scale (CKRS), IKDC, subjective evaluation and X-ray and MRI control. There were no complications related to the device. All patients were able to return to day activities without limitations 3 months after surgery. Both subjective CKRS score and objective IKDC score showed improvement in all cases except one patient with an ACL re-injury. In two cases scores were slightly worse from 2 years after surgery to the final observation point. The other five cases obtained maximum score at final follow-up. In four cases the absence of pain remained until the final observation point, while in four cases a low entity of pain was described at long term follow-up. MRI showed in five cases mixoid degeneration signal, two had normal signal with reduced size, while one patient had no recognizable implant. Six patients had preserved cartilage and articular space, with no changes respect to pre-op control. Arthroscopic second look evaluation has been performed in three cases, revealing in two cases the presence of the implant, although with a reduced size respect to the original one, while in one case the CMI was almost disappeared. Our small series of eight patients prospectively followed from 6 to 8 years of follow-up has shown highly satisfactory results. Although the aspect of the implant was mostly abnormal, the implant may have helped reduce the deterioration of the knee joint at final observation time.

This text provides essential information needed to serve the large population of young athletic patients with cartilage defects who are not yet candidates for joint arthroplasty. Nearly 350 illustrations facilitate the understanding of examination and operative techniques, including arthroscopic debridement, electrothermal chondroplasty, marrow stimulation, osteochondral autograft transfer (OATS/Mosaicplasty), autologous chondrocyte implantation, and osteochondral allografting. The text also addresses joint specific injuries in the shoulder, elbow, and ankle that are often neglected in other literature. Key Features: Reviews normal cartilage anatomy and cartilage response to injury to illuminate appropriate treatment techniques and healing processes. Covers non-operative techniques including analgesics, oral anti-inflammatory medications, neutraceuticals, and hyaluronic acid injections/viscosupplementation, allowing the clinician to expand treatment options. Descriptions of adjunctive procedures, such as meniscal transplant and corrective osteotomy. Provides insights on future directions in the detection and treatment of cartilage injuries.

Purpose: To prospectively evaluate the mosaicplasty technique for treatment of femoral condyle cartilage lesions (Outerbridge grade IV) less than 2.5 cm 2 in homogeneous group of young active patients. Type of study: Case series. Methods: Thirty-seven patients (10 female, 27 male; mean age, 29.5 years) with full-thickness knee chondral lesions were treated by the arthroscopic mosaicplasty technique. All patients practiced sports. There were 12 ACL reconstructions, 11 medial meniscectomies, and 8 lateral meniscectomies associated; 10 meniscectomies, 9 ACL reconstructions, and 5 cartilage reparative operations had been previously performed. All patients were evaluated at a 2-year follow-up. The International Cartilage Repair Society (ICRS) form, return to sports, computed tomography, or magnetic resonance imaging were used for clinical evaluation. In some cases, second-look arthroscopy was performed. Results: The ICRS showed 78.3% good and excellent results; 27 patients returned to sports at the same level and 5 at a lower level, but 5 were not able to resume sports. Results in the lateral condyles were significantly better than those in medial condyles, and younger patients had a better clinical outcome than did older patients. Cases with associated surgery had better clinical results; previous surgery did not significantly influence the clinical outcome. Conclusions: xy The results of this technique at medium-term follow-up are encouraging with 78.3% clinically satisfactory results. Better results can be obtained in young patients with associated surgery, with localized grade 4 lesions of the lateral condyles. This arthroscopic 1-step surgery appears to be a valid solution for the treatment of grade III-IV cartilage defects not more than 2.5 cm 2 . Level of evidence Level IV, Case Series.

We investigated the clinical and laxity testing results at 5 years' followup in patients who had early or late anterior cruciate ligament reconstruction. Twenty-three patients (Group I) were treated within 15 days of injury. Fifty-nine patients (Group II) were treated more than 3 months after injury. Patellar tendon reconstruction and fascia lata graft augmented with a ligament augmentation device were the techniques used in both groups. According to the Inter national Knee Documentation Committee rating scale, 17 patients in Group I and 38 patients in Group II had satis factory results. The Lysholm score was good in all Group I patients and in 55 Group II patients. Flexion-extension deficits were comparable for both groups. Eighteen pa tients (78%) in Group I demonstrated satisfactory results according to the KT-2000 arthrometer testing, compared with 44 (75%) in Group II. No associated lesions were present in 12 (52%) cases in Group I, compared with 26 (44%) cases in Group II. Return to sports at the preop erative level was obtained by 21 (91 %) patients in Group I, compared with 42 (71 %) in Group II. The patients who had reconstruction during the early phase returned to sports activities sooner and had better clinical and laxity testing results.

differences in the outcome, but we believe that also modifications in the technique represent important variables. Purpose of this study was to compare result~ of Caspari technique with a personally modified one to evaluate the effectiveness of our technical changes, Arthroscopic treatment was performed on 71 patients with recurrent shoulder dislocations, Patient selection includes only patients with monoplanar anterior instability. Of the 71 operations, 29 were performed using original Caspari technique (follow-up 59 months) and 42 were performed after modifications made in the original technique (follow up 38 months), notably improved preparation of the capsular re-insertion zone, increase in the number of monofilament points and their anchorage directly to the bone, on the spine of the scapula. Comparison of the results obtained in these two differently treated groups was executed analyzing the number of dislocation episodes prior to the operation, as well as clinical, findings regarding, stability, movement, function and pain (Rowe scale score), contralateral shoulder laxity, resumption of sport activity and postoperative recurrence rate, Student test and correlation coefficient test were used for statistical analysis.