Pediatric Anterior Cruciate Ligament Reconstruction With Over-the-Top Femoral Position and All-Epiphyseal Tibial Tunnel.

In pediatric anterior cruciate ligament reconstruction, many factors should be considered: (1) risk of growth disturbance; (2) high risk of re-tear; (3) determination of the skeletal age, which is sometimes challenging; and (4) no single technique indicated for all patients. The choice of the technique mostly depends on the patients' age and growth potential. Whereas prepubescent patients can be safely treated with physeal sparing techniques (i.e., the Kocher-Micheli technique or its modifications), in postpubescent patients physeal respecting or adult-type reconstructions are generally indicated. In pubescent patients, both all-inside all-epiphyseal and partial transphyseal techniques can be safely performed, but these are not without shortcomings. With the goal of overcoming some of the drawbacks of the existing techniques, the authors describe this technical note. The technique entails an over-the-top femoral position of a 6-strand hamstring graft and an all-epiphyseal tibial tunnel. The femoral physis is completely preserved, and only a 4.5 mm transphyseal tunnel is drilled in the tibia with an all-epiphyseal tibial half socket. With this technique, the graft diameter is adequate, there is no need for fluoroscopy, no risk of graft/tunnel mismatch, and a modified Arnold-Coker lateral tenodesis can be associated via the same lateral incision.

Mathematical explanations for knee osteotomies: "Dear engineer, how would you explain it in a simple way?"

INTRODUCTION: Knee osteotomies are effective procedures to treat different deformities and to redistribute the load at the joint level, reducing the risk of wear and, consequently, the need for invasive procedures. Particularly, knee osteotomies are effective in treating early arthritis related to knee deformities in young and active patients with high functional demands, with excellent long-term results. Precise mathematical calculations are imperative during the preoperative phase to achieve tailored and accurate corrections for each patient and avoid complications, but sometimes those formulas are challenging to comprehend and apply. METHODS: Four specific questions regarding controversial topics (planning methods, patellar height, tibial slope, and limb length variation) were formulated. An electronic search was performed on PubMed and Cochrane Library to find articles containing detailed mathematical or trigonometrical explanations. A team of orthopedic surgeons and an engineer summarized the available Literature and mathematical rules, with a final clear mathematical explanation given by the engineer. Wherever the explanation was not available in Literature, it was postulated by the same engineer. RESULTS: After the exclusion process, five studies were analyzed. For three questions, no studies were found that provided mathematical analyses or explanations. Through independent calculations, it was demonstrated why Dugdale's method underestimates the correction angle compared to Miniaci's method, and it was shown that the variation in patellar height after osteotomy can be predicted using simple formulas. The five included studies examine postoperative variations in limb length and tibial slope, providing formulas applicable in preoperative planning. New formulas were independently computed, using the planned correction angle and preoperatively obtained measurements to predict the studied variations. CONCLUSIONS: There is a strict connection among surgery, planning, and mathematics formulas in knee osteotomies. The aim of this study was to analyze the current literature and provide mathematical and trigonometric explanations to important controversial topics in knee osteotomies. Simple and easy applicable formulas are provided to enhance the accuracy and outcomes of this surgical procedure.

How to manage a native stiff knee.

Knee stiffness is a widely known and worrying condition in several postoperative knees. Less is known about native stiff knee. The aim of this manuscript is to summarize the available literature on native stiff knee epidemiology, classification and treatment. In 1989 stiff knee was defined as a knee with less than 50° of total range of motion. If range of motion is <30°, it is defined as an ankylosed knee. Knee stiffness can be divided into three main types: flexion contractures, extension contractures, and combined contractures. Different risk factors have been associated to native stiff knee and grouped into modifiable or not modifiable. Furthermore, risk factors can be divided into patients' related no patients'-related. Different treatment modalities can be indicated to treat knee stiffness, including manipulation under anesthesia (MUA), arthroscopic and open surgical release. When stiffness is associated with articular disruption TKA represent an option. TKA in native stiff knee can be challenging for the surgeon. Implant's choice and knee exposure are the first steps. In some cases, additional release and extensive can be considered. A stepwise approach and careful preoperative planning are mandatory to obtain long-term satisfactory outcomes. Native stiff knee is a rare but invalidating condition. Different treatment modalities have been proposed as treatment. However, considering that it is frequently associated to sever arthritis, TKA can be an option in painful stiff knees. Nature of knee stiffness necessitates a customized approach to ensure successful management and achieve satisfying outcomes.

Direct healthcare costs of oral cancer: A retrospective study from a tertiary care center.

The aim of this study was to retrospectively evaluate the direct costs of OSCC treatment and postsurgical surveillance in a tertiary hospital in northeast Italy. Sixty-three consecutive patients surgically treated for primitive OSCC at S. Orsola Hospital in Bologna (Italy) between January 2018 and January 2020 were analyzed. Billing records of the Emilia Romagna healthcare system and institutional costs were used to derive specific costs for the following clinical categories: operating theatre costs, intensive and ordinary hospitalization, radiotherapy, chemotherapy, postsurgical complications, visits, and examinations during the follow-up period. The study population comprised 17 OSCC patients classified at stage I, 14 at stage II, eight at stage III, and 24 at stage IV. The estimated mean total direct cost for OSCC treatment and postsurgical surveillance was €26 338.48 per patient (stage I: €10 733, stage II: €19 642.9, stage III: €30 361.4, stage IV: €39 957.2). An advanced diagnosis (stages III and IV), complex surgical procedure, and loco-regional recurrences resulted in variables that were significantly associated with a higher cost of OSCC treatment and postsurgical surveillance. Redirection of funds used for OSCC treatment to screening measures may be an effective strategy to improve overall health outcomes and optimize national health resources.

Active surveillance for clinical complete responders after chemoradiotherapy for oesophageal squamous cell carcinoma.

BACKGROUND: Guidelines on the treatment of oesophageal squamous cell carcinoma (SCC) recommend neoadjuvant chemoradiotherapy plus surgery or definitive chemoradiotherapy. The aim of this study was to evaluate the outcome of patients with a cCR after chemoradiotherapy who underwent active surveillance. METHODS: Patients with oesophageal SCC who were treated with chemoradiotherapy between January 2016 and June 2022 were identified from an institutional database. Survival and recurrence of patients with a cCR who underwent active surveillance were compared with those of patients who underwent planned surgery. Survival was calculated according to the Kaplan-Meier method and compared between groups using the log rank test. RESULTS: The 37 patients who underwent active surveillance were older and tumours were more often located in the middle/upper-third of the oesophagus than in the surgery group of 57 patients. Median follow-up was 28.1 (i.q.r. 17.2-47.1) months for the active surveillance group and 20 (12.9-39.1) months for the surgery group. Overall survival was comparable between the two groups, with 3-year survival rates of 50 (95% c.i. 31 to 67) and 59 (40 to 73)% for the active surveillance and surgery groups respectively (P = 0.55). Three-year progression-free survival for patients who underwent active surveillance was better than in the surgery group: 70 (43 to 85) versus 58 (40 to 72)% (P = 0.02). Overall and progression-free survival was comparable between patients in the active surveillance group and 23 patients in the surgery group who had a pCR (ypT0 N0). The overall recurrence rate was comparable between the groups: 7 of 37 (19.4%) in active surveillance group versus 16 of 49 (32.6%) in surgery group (P = 0.26). Locoregional recurrence was noted more often in the active surveillance group and systemic recurrence in the surgery group. CONCLUSION: Active surveillance is feasible and safe for patients with oesophageal SCC who have a cCR after chemoradiotherapy.

Lateral Extra-Articular Tenodesis with Indirect Femoral Fixation Using an Anterior Cruciate Ligament Reconstruction Suspensory Device.

BACKGROUND: The lateral extra-articular tenodesis (LET) procedure associated with anterior cruciate ligament (ACL) reconstruction can be considered in selected patients to diminish the risk of persistent rotatory instability and achieve a protective effect on the graft. Several techniques have been described in the literature to treat rotatory instability. Usually, a strip of the iliotibial band (ITB) is harvested from its middle while leaving the distal insertion, then passed underneath the lateral collateral ligament and fixed on the lateral aspect of the distal femur with various fixation methods such as staples, screws, anchors or extracortical suspensory devices. Despite their effectiveness, these fixation methods may be associated with complications such as lateral pain, over-constraint and tunnel convergence. METHODS: This study presents a detailed surgical description of a new technique to perform an LET during ACL reconstruction with any type of graft fixing the ITB strip with the sutures of the ACL femoral button, comparing its pros and cons in relation to similar techniques found in the literature. CONCLUSIONS: This technique represents a reproducible, easy to learn and inexpensive solution to perform a lateral extra-articular tenodesis associated with an ACL reconstruction using the high-resistance sutures of the femoral button.

Thirteen-gene DNA methylation analysis of oral brushing samples: A potential surveillance tool for periodic monitoring of treated patients with oral cancer.

BACKGROUND: We evaluated the prognostic role of 13-gene DNA methylation analysis by oral brushing repeatedly performed during the follow-up of patients surgically treated for oral cancer. METHODS: This is a nested case-control study including 61 patients for a total of 64 outcomes (2/61 patients experienced multiple relapses). Samples were collected at baseline (4-10 months after OSCC resection) and repeatedly every 4-10 months until relapse or death. DNA methylation scores were classified as persistently positive, persistently negative, or mixed. RESULTS: Twenty cases who had persistently positive scores and 30 cases with mixed scores had, respectively, an almost 42-fold (p < 0.001) and 32-fold (p = 0.006) higher likelihood of relapse, compared to 14 patients with persistently negative scores. The last score before reoccurrence was positive in 18/19 secondary events. CONCLUSIONS: The 13-gene DNA methylation analysis may be considered for the surveillance of patients treated for oral carcinoma.

Pre-operative incisional biopsy of oral squamous cell carcinoma: high podoplanin expression is related to perineural invasion and may be a useful predictor of disease progression.

OBJECTIVE: Immunohistochemical analysis of podoplanin expression as a pre-operative molecular marker for perineural invasion (PNI) may represent an attractive strategy for surgical management of oral squamous cell cancer (OSCC). We evaluated the relationship between podoplanin expression and PNI in pre-operative incisional biopsies of OSCC. STUDY DESIGN: After performing pathological staging and histologic and immunohistochemical evaluation of 83 surgical specimens, we performed multivariable logistic regression analysis to examine the relationship between PNI and independent variables. To evaluate the utility of podoplanin immunopositivity for discrimination of PNI status pre-operatively, we calculated the sensitivity, specificity, positive predictive value, and negative predictive value. We performed receiver operating characteristic curve analysis to evaluate the diagnostic accuracy of podoplanin immunopositivity for predicting PNI alone and in combination with age, T stage, N stage, and index site. RESULTS: We observed podoplanin expression in 42 (50.6%) of all the 83 pre-operative incisional biopsies and 29 of the pre-operative biopsies of the 31 (93.5%) postoperative specimens with PNI. The rate of podoplanin expression was significantly higher in patients with pT3 to pT4 stage and pN+ stage disease. Podoplanin positivity in the pre-operative biopsy showed high sensitivity in predicting PNI in the surgical specimen. CONCLUSION: Podoplanin expression appears to be an independent pre-operative variable significantly related to PNI and a possibly valuable prognostic marker for therapeutical planning and surgical treatment of OSCC.

The Use of Nano-Hydroxyapatite (NH) for Socket Preservation: Communication of an Upcoming Multicenter Study with the Presentation of a Pilot Case Report.

Background and Objectives: The use of biomaterials in dentistry is extremely common. From a commercial perspective, different types of osteoconductive and osteoinductive biomaterials are available to clinicians. In the field of osteoconductive materials, clinicians have biomaterials made of heterologous bones at their disposal, including biomaterials of bovine, porcine, and equine origins, and biomaterials of natural origin, such as corals and hydroxyapatites. In recent years, it has become possible to synthesize nano-Ha and produce scaffolds using digital information. Although a large variety of biomaterials has been produced, there is no scientific evidence that proves their absolute indispensability in terms of the preservation of postextraction sites or in the execution of guided bone regeneration. While there is no scientific evidence showing that one material is better than another, there is evidence suggesting that several products have better in situ permanence. This article describes a preliminary study to evaluate the histological results, ISQ values, and prevalence of nano-HA. Materials and Methods: In this study, we planned to use a new biomaterial based on nanohydroxyapatite for implantation at one postextraction site; the nano-HA in this study was NuvaBONE (Overmed, Buccinasco, Milano, Italy). This is a synthetic bone graft substitute that is based on nanostructured biomimetic hydroxyapatite for application in oral-maxillofacial surgery, orthopedics, traumatology, spine surgery, and neurosurgery. In our pilot case, a patient with a hopeless tooth underwent extraction, and the large defect remaining after the removal of the tooth was filled with nano-HA to restore the volume. Twelve months later, the patient was booked for implant surgery to replace the missing tooth. At the time of the surgery, a biopsy of the regenerated tissue was taken using a trephine of 4 mm in the inner side and 8 mm deep. Results: The histological results of the biopsy showed abundant bone formation, high values of ISQ increasing from the insertion to the prosthetic phase, and a good reorganization of hydroxyapatite granules during resorption. The implant is in good function, and the replaced tooth shows good esthetics. Conclusions: The good results of this pilot case indicate starting the next Multicentric study to have more and clearer information about this nanohydroxyapatite (NH) compared with control sites.

The Poncho Lamina Technique: A Protocol for Hard and Soft Tissue Augmentation in Atrophic Ridges Receiving Adjacent Implants.

The current scientific knowledge and guidelines in bone and soft tissue augmentation suggest the use of staged surgical workflows as the gold standard of regenerative procedures during implant therapy. In this context, the process is always the same, regardless of the techniques applied: an alternate series of surgical acts that follow one another after the completion of a specific period of osseointegration or graft maturation. As a result, the overall surgical treatment is often long and invasive and induces scar tissue formation. This article proposes a novel, fast, and less-invasive biphasic protocol with the use of a well-documented cortical barrier mounted on healing screws that are further replaced by customized abutments at an early second stage. Two cases are reported, one for an upper maxillary edentulous area and the other for a mandibular, with a total of four implants placed. The results at 4 months postop showed an optimal soft tissue configuration for both cases, with adequate cervical profile generation and a sufficient supracrestal complex height above the implant platforms. Significant bone gains were also recorded through CBCT data collection, either with alveolar width measurements on axial slices, the superposition of pre-op and post-op datasets, or 3D visualization after bone volume segmentation.

A new three-dimensional patient-specific cutting guide for opening wedge high tibial osteotomy based on ct scan: preliminary in vitro results.

PURPOSE: The aim of this study was to evaluate the accuracy of a patient-specific cutting guide on both coronal and sagittal alignment compared to the pre-operative planning in OWHTO. METHODS: Twelve OWHTO on 6 cadaveric specimens were performed by 3 experienced knee surgeons using patient-specific cutting guides based on 3D pre-operative planning. Since the specimens had no major deformities, a fixed correction of 6° on the left and 10° on the right legs were carried out to simulate different scenarios. A pre-operative and post-OWHTO 3D CT scans were performed, and images were superimposed using the dedicated 3D planning software to align their reference axes. A pre-operative planning was performed considering both Medial Proximal Tibial Angle (MPTA) and Posterior Tibial Slope (PTS), and a patient-specific cutting guide was produced. Planned and post-OWHTO MPTA and PTS were evaluated (mean and standard deviation), and Pearson's correlation coefficient was calculated to assess precision and accuracy of the whole treatment. RESULTS: A mean correction of 6,1° (SD 1,9°) and 1,2° (SD 1°) was obtained respectively in the coronal plane (MPTA) and in the sagittal plane (PTS). The average difference between planned and post-OWHTO MPTA and PTS was respectively 1,2° (SD 0,6°) and 1,2° (SD 1°) in the sagittal plane (PTS). Pearson's correlation coefficient demonstrated a good accuracy of the treatment in both coronal and sagittal plane (respectively r=0,95 and r=0,86). No lateral hinge fractures were detected at the post-operative CT scan. CONCLUSION: OWTHO performed with the help of 3D patient specific cutting guide on cadaveric specimens demonstrated good accuracy and reliability in obtaining the planned correction. In vivo studies are necessary to confirm these results and evaluate cost-effectiveness of this system. LEVEL OF EVIDENCE: Level IV cadaveric study.

Surgical management of gingival recessions in patients with refractory gingival pemphigus vulgaris: A multidisciplinary challenge.

BACKGROUND: Mucogingival surgery for root coverage of gingival recessions (GRs) is usually performed in patients with unremarkable periodontal and systemic health. However, the predictable results of surgical procedures and increasingly high aesthetic expectations of patients necessitate optimal management of GR also in patients with systemic conditions that affect the oral cavity. In patients with pemphigus vulgaris (PV), mucosal fragility and complicated surgical management of inflamed soft tissues are major challenges. METHODS AND RESULTS: A 36-year-old female patient with PV and deep GR on the mandibular incisors is presented. After initial unresponsiveness to steroids and immunosuppressants, complete clinical remission was achieved through repeated rituximab infusions and topical platelet-rich plasma. After > 1 year of stable clinical remission off therapy the patient successfully underwent surgical procedures for vertically coronally advanced flap with connective tissue graft. CONCLUSIONS: To the best of our knowledge, no studies have described the surgical management of GR in PV patients. Although controlled studies are required to confirm present results, complete and stable clinical remission is necessary to avoid complications. Collaboration among dermatologists, oral medicine specialists, and periodontologists is essential to determine whether mucogingival surgery for root surface exposure is indicated for PV patients. KEY POINTS: Why are these cases new information? This is the first report of root coverage in a patient with oral PV What are the keys to the successful management of these cases? The achievement of complete and stable clinical remission from oral PV Multidisciplinary collaboration among dermatologists, oral medicine specialists, and periodontologists What are the primary limitations to success in these cases? The refractoriness of gingival lesions induced by PV Poor mucogingival conditions of inflamed gingival tissues exacerbated by PV.

Primary TKA in patients with major deformities and ligament laxities: promising results of an intermediate constrained implant at mid-term follow-up.

BACKGROUND: Total knee arthroplasty (TKA) in major deformities with ligament insufficiency may require a higher constraint, with bone sacrifice and concerns about long-term survivorship. Mid-level constraint liners have been recently introduced, but few studies described their outcomes. The aim of this study is to evaluate the short to mid-term outcomes of a constrained postero-stabilized (CPS) insert for primary TKA in moderate to severe deformities. METHODS: All patients who underwent TKA using a CPS liner in two centers between 2015 and 2017 were included in the study. The indications were: (1) valgus deformity type 2-3 partially correctable; (2) severe varus deformity with varus thrust; (3) post-traumatic deformity with major ligamentous insufficiency and any case of intra-operative ligament insufficiency. Patients were evaluated according to the Knee Society Scoring System (KSS), the Hospital for Special Surgery score (HSS), the Western Ontario and Mc Master University (WOMAC) and the Oxford Knee score (OKS). X-rays were evaluated according to the Knee Society Roentgenographic Evaluation System. RESULTS: Forty-seven TKA were included, with an average age of 66.1 ± 10.3 years and an average follow-up of 68.4 ± 6 months. All patients demonstrated a moderate to severe pre-operative mediolateral instability. All the scores significantly improved (p < 0.0001). In 71.4% of cases, the outcomes were excellent or very good. There were no failures due to aseptic loosening but one failure due to a traumatic ligament rupture. The cumulative survivorship was 97.9% ± 2.1% at 84 months. CONCLUSIONS: This mid-range constraint total knee replacement demonstrated promising outcomes and survival at mid-term follow-up. LEVEL OF EVIDENCE: IV (case series).

Transepicondylar distance measured on MRI can predict the length of the graft required for different anterior cruciate ligament reconstruction (ACLR) techniques useful for revision surgery.

BACKGROUND: The aim of this study is to find a correlation between linear measurements and the graft length required for different anterior cruciate ligament (ACL) revision techniques, to extract formulas to predict required graft length during the preoperative planning. METHODS: At time 0 and 30 days later, two observers measured eight linear distances on standard 2D knee magnetic resonance imaging (MRI), and nine curved distances on 3D MRI sequences, corresponding to different techniques for ACL revision, anatomic anterolateral ligament (ALL) reconstruction, and lateral extrarticular tenodesis (LET). Intra- and interobserver reliability was tested for 2D and 3D measurements. The correlation between 2D and 3D measurements was tested. The 2D measurements with highest repeatability and reproducibility, and with strongest correlation with 3D measurements were used to extract formulas to calculate the graft length from 2D values. RESULTS: Fifty MRIs acquired with both 2D and 3D sequences were used. The intra- and interobserver reliability of linear 2D measurement was high, with the transepicondylar distance (TD) showing the highest reproducibility and repeatability. The intra- and interobserver reliability of 3D measurements was lower than 2D, but acceptable for all measurements except for ALL reconstruction. The TD showed the strongest correlation with 3D measurements. The formulas extracted to calculate the graft length from the TD proved to be accurate. CONCLUSION: Accurate formulas were created to calculate the graft length needed for different ACL revision techniques and ALL reconstruction/LET techniques from TD. These formulas can be used during preoperative planning of ACL revision cases.

Double guide concept: A new digital paradigm for the treatment of altered passive eruption in patients with high esthetic expectations.

Digital guides (also known as stents) have become commonly used in daily dental practice. CBCT, digital impressions, and stereolithographic models are considered extremely helpful to create guides for the planning and resolution of surgical cases. In recent years, in periodontal surgery and in particular for the treatment of altered passive eruption (APE), there has been an increasing use of digitally designed guides to improve esthetic outcomes and achieve more predictable results. Digital custom-made guides can be used to improve safety and precision in crown lengthening procedures in patients with APE who have high esthetic expectations. Although most approaches described in the literature show guides used for primary flap or gingivectomy design, the precision of bone recontouring and ostectomy plays a key role in soft tissue rebound and in the final esthetic outcome. The present article describes a new approach using two different guides for soft tissue design in patients with APE.

Photodynamic Therapy by Mean of 5-Aminolevulinic Acid for the Management of Periodontitis and Peri-Implantitis: A Retrospective Analysis of 20 Patients.

Periodontitis and peri-implantitis are common in the population worldwide. Periodontal diseases affect approximately 50% of adults, while mucositis affects 80% of patients with implants, turning into peri-implantitis at a rate varying from 28 to 58%. If standardized treatments for all degrees and variety of periodontal diseases are known and codified, a consensus on the treatment of peri-implantitis still has to be found. Photodynamic therapy (PDT) has been used successfully in the medical field and was recently introduced as supportive therapy in dentistry. This paper reviews the results on 20 patients, 10 affected by periodontal disease (grades II to III) and 10 by peri-implantitis. Application of 5% 5-aminolevulinic acid gel (ALAD), as a support of causal therapy, in periodontal pockets and areas of peri-implantitis favored the maintenance of severely compromised teeth and significantly improved compromised implant conditions. Between baseline and 6 months, all teeth and implants remained functional. All patients confirmed that the scaling and root planning (SRP)+ALAD-PDT was not painful, and all perceived a benefit after the treatment at all timing points. For periodontal patients, a significant decrease in PPD after 3 (p < 0.001) and 6 months after SRP+ALAD-PDT respect baseline values were observed. For the implant patients, the SRP+ALAD-PDT was correlated to a decrease in PPD and BOP, and a slight increase in the number of exposed threads. However, the results were statistically significant only for PPD (p < 0.001).

Tibial tubercle osteotomy for patellofemoral malalignment and chondral disease provided good outcomes: A systematic review.

IMPORTANCE: Tibial tubercle osteotomy (TTO) is indicated to treat patellofemoral (PF) malalignment and chondral disease refractory to conservative treatment. However, there are no systematic reviews describing TTO outcomes in chondral damages without instability. AIM: The aims of this study were to (1) assess the quality of the published studies, (2) identify indication for TTO to treat PFP with chondral disease without instability, (3) evaluate the most common TTO techniques, (4) evaluate the clinical outcomes, and (5) evaluate TTO's complication and failure rates. EVIDENCE REVIEW: In December 2020, a literature search was performed applying the following criteria: (1) peer-reviewed Level 1-4 studies; (2) English language; (3) human subjects with clinical and/or radiological outcomes; (4) TTO alone or associated with minor cartilage procedure (only drilling, no instability); (5) minimum follow-up 12 months, minimum 10 patients; and (6) no more than 20% of drop-out rate. Data from studies were collected and described with weighted averages and standard deviations. FINDINGS: A total of 18 Level 4 studies were included. The average Coleman Methodology Score was 61.5 points (range 48-81). A total of 851 patients (892 knees) were included, with 64.8% of female patients. The weighted average follow-up was 49.1 months (range 12-128.5). Indication for TTOs was poorly described. The main technique used was anteromedialisation (60.4%). In 27.7% of the cases, TTO was associated with lateral release. Different scoring systems were used to evaluate outcomes, with significant improvements. The average rate of good/excellent results was 78.7% (range 57%-100%). Fifteen studies described the complication rate (9.9%), whereas only four reported the failure rate (6.2%). CONCLUSION AND RELEVANCE: TTOs performed to treat PF malalignment associated with chondral disease without instability provided good clinical outcomes, with acceptable complication/failure rates. However, high-level studies are necessary because of studies' heterogeneity regarding patellofemoral malalignment and chondral disease treatment. STUDY DESIGN AND LEVEL OF EVIDENCE: Systematic review. LEVEL OF THE STUDY: Level IV, systematic review of Level IV studies.

Computed tomography-based radiomic to predict resectability in locally advanced pancreatic cancer treated with chemotherapy and radiotherapy.

BACKGROUND: Surgical resection after neoadjuvant treatment is the main driver for improved survival in locally advanced pancreatic cancer (LAPC). However, the diagnostic performance of computed tomography (CT) imaging to evaluate the residual tumour burden at restaging after neoadjuvant therapy is low due to the difficulty in distinguishing neoplastic tissue from fibrous scar or inflammation. In this context, radiomics has gained popularity over conventional imaging as a complementary clinical tool capable of providing additional, unprecedented information regarding the intratumor heterogeneity and the residual neoplastic tissue, potentially serving in the therapeutic decision-making process. AIM: To assess the capability of radiomic features to predict surgical resection in LAPC treated with neoadjuvant chemotherapy and radiotherapy. METHODS: Patients with LAPC treated with intensive chemotherapy followed by ablative radiation therapy were retrospectively reviewed. One thousand six hundred and fifty-five radiomic features were extracted from planning CT inside the gross tumour volume. Both extracted features and clinical data contribute to create and validate the predictive model of resectability status. Patients were repeatedly divided into training and validation sets. The discriminating performance of each model, obtained applying a LASSO regression analysis, was assessed with the area under the receiver operating characteristic curve (AUC). The validated model was applied to the entire dataset to obtain the most significant features. RESULTS: Seventy-one patients were included in the analysis. Median age was 65 years and 57.8% of patients were male. All patients underwent induction chemotherapy followed by ablative radiotherapy, and 19 (26.8%) ultimately received surgical resection. After the first step of variable selections, a predictive model of resectability was developed with a median AUC for training and validation sets of 0.862 (95%CI: 0.792-0.921) and 0.853 (95%CI: 0.706-0.960), respectively. The validated model was applied to the entire dataset and 4 features were selected to build the model with predictive performance as measured using AUC of 0.944 (95%CI: 0.892-0.996). CONCLUSION: The present radiomic model could help predict resectability in LAPC after neoadjuvant chemotherapy and radiotherapy, potentially integrating clinical and morphological parameters in predicting surgical resection.